INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12& 13, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPASS Asian Outpatient Counseling Service was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of employee #1's job description and the project's organizational chart, the project failed to ensure that the staff person appointed to the position of project director would be responsible for the overall management of the project and staff.
The findings include:
The published definition for project director as found in 28 Pa. Code, 701.1 is as follows:
Project director - The administrator of the treatment project who is responsible
for the overall management of the project and staff and who meets the education
and experience requirements in Chapter 704.
Employee # 1 was hired in 2008. On July 1, 2011, employee # 1 was promoted to the position of the Project Director. The job description includes a listed duty to serve as project director. On September 15, 2011 employee #1's job description was reviewed along with the project's organizational chart
The job description for the Project Director does not specify that employee #1 is responsible for the overall management of the project and staff.
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Plan of Correction
The project director's job description was revised to reflect compliance with the state regulations.
The program description now indicates that the project director will now be responsible for the overall management of project and staff.
The revised project director job description will be faxed to the surveyor for approval.
In addition, to ensure that this does not happen again, before a program description is approved it will be reviewed to ensure it is in comliance with the job descriptions stated in state regulations. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, and an interview with the director, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment.
All other staff shall complete the training within the first 2 years of employment.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on September 13, 2011.
Two employees identified on the Staffing Requirements Facility Summary Report, employees #7 & 8 were required to have documentation of HIV/AIDS and TB/STD training; however, per the Staffing Requirements Facility Summary Report the employees had not completed the training.
The facility failed to provide documentation of the required HIV/AIDS and TB/STD training for employee # 7 and 8.
Employee # 7 was hired January 9, 2009.
Employee # 7 is a Stop Addiction For Ever (SAFE) Coordinator.
HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment, by January 9, 2011.
At the time of review on September 13, 2011, employee # 7 had not received the STD/TB training.
Employee # 8 was hired January 28, 2008.
Employee # 8 is an administrative assistant.
HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment, by January 28, 2010.
At the time of review on September 13, 2011, employee # 8 had not received HIV/AIDS training.
The director confirmed the finding during an interview on September 13, 2011 at 12:55 PM.
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Plan of Correction
Employees 7 and 8 have been registered for TB/STD training on November 30, 2011.
Employees 7 and 8 have been registered for HIV training on November 3, 2011.
To ensure that this does not occur again, clinical supervisor/project director will complete a quarterly review of the training record of employees to ensure they complete mandated trainings. Clinical supervisor/project director will schedule required trainings. If an employee fails to complete the mandated trainings, he/she will be suspended until the trainings are completed. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and a review of the facilities policy and procedures manual, the facility failed to document a psychosocial evaluation according to policy in three of five records.
The findings include:
The facilities policy titled "Psychosocial evaluation" states:
The psychosocial evaluation must be completed within thirty days of admission to outpatient. It is the counselor's evaluation of the discretion of the physician. The evaluation should provide a composite picture of the individual in relationship to the collected historical information, in order to identify possible relationships, conditions and causes leading to the client's current situation. It is recommended that this evaluation include: a clear description of the client's presenting and underlying problems; client needs or weaknesses that can or cannot be resolved through treatment or that might inhibit treatment; client's assets, strengths or other factors that can contribute to the resolution of identified problems; the potential or available client support systems; negative factors that might affect treatment; the client's coping mechanisms to deal with stress; conclusions regarding the client's appearance, behavior and reactions during the intake and history-taking process; and conclusions regarding the client's attitude towards and ability to participate in the treatment process.
Five client records were reviewed on September 13, 2011 for documentation of a psychosocial evaluation.
The facility failed to document a psychosocial evaluation according to policy in three of five client records reviewed, # 1, 2, and 3.
Client # 1 was admitted to the program on 4/15/11.
The psychosocial was documented on 5/10/11.
However, the facility failed to document an evaluation that included a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's situation.
In addition, the psychosocial evaluation failed to include a clear description of the client's presenting and underlying problems; the client's needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; the potential or available client support systems; negative factors that might affect treatment; and the client's coping mechanisms to deal with stress.
Furthermore, the evaluation failed to include the client's appearance, behavior and reactions during the intake and history-taking process; and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 2 was admitted to the program on 3/16/11.
The psychosocial was documented on 3/21/11.
However, the facility failed to document an evaluation that included a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's situation.
In addition, the psychosocial evaluation failed to include a clear description of the client's presenting and underlying problems; the client's needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; the potential or available client support systems; negative factors that might affect treatment; and the client's coping mechanisms to deal with stress.
Furthermore, the evaluation failed to include the client's appearance, behavior and reactions during the intake and history-taking process; and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 3 was admitted to the program on 6/9/11.
The psychosocial was documented on 6/17/11.
However, the facility failed to document an evaluation that included a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's situation.
In addition, the psychosocial evaluation failed to include a clear description of the client's presenting and underlying problems; the client's needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; the potential or available client support systems; negative factors that might affect treatment; and the client's coping mechanisms to deal with stress.
Furthermore, the evaluation failed to include the client's appearance, behavior and reactions during the intake and history-taking process; and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
During the exit interview the findings were discussed with the project director and clinical supervisor. It was determined that the documented psychosocial evaluation was not evaluative, it was a historical summary which documented and repeated what "the client reports/purports."
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Plan of Correction
The Biopsychosocial Assessment Clinical Summary for clients 1, 2 and 3 was rewritten to reflect the clinician's evaluation of the respective client's: coping skills, strengths, barriers and other clinical elements from the assessment itself.
To ensure this deficiency does not occur in the future, the Biopsychosocial Assessment Clinical Summary has been revised to Biopsychosocial Clinical Summary Assessment. The counselors will be trained/re-trained on how to appropriately make assessment in this are of the biopsychosocial assessment to reflect their clinical judgment.
In addition, on-going individual and group training will occur with the staff to ensure this section of the Biopsychosocial is completed properly. The clinical supervisor/project director will review the Biopsychosocial Assessment with the counselors during individual and group supervision to ensure this is being done.
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