INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the September 12 & 13, 2011 licensure renewal inspection. The follow-up inspection was conducted on March 14, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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.
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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 the project's current organizational chart, the project failed to ensure that the appropriate staff person had been appointed to the position of project director.
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.
The current organization chart for GPASS continues to list an Executive Director position in addition to the position of Project Director. Based on the organizational chart, the Executive Director is the person who performs the duties of Project Director.
This is a repeat citation.
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Plan of Correction
The Board of Directors has revised the organizational chart to establish compliance with 28 PA. Code, 701.1 for the position of Project Director.
The current organization chart list the Project Director as the person who is officially responsible to the governing body. The Project Director has a BSN and 13 years of experience and is therefore qualified and responsible for the overall management of the project and staff.
The board will continue to monitor and adhere to state regulations, 28 Pa. Code, 701.1.
Our board of directors and Executive Director will review state regulations and the organizational chart on a yearly basis to ensure that the regulations are adhered to.
Corrective action date: 6/19/12 |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records and clinical documentation, the facility failed to adhere to the requirements specified at 4 Pa. Code subsection 255.5 (b) and 42 CFR Part 2, Subpart C, subsection 2.31 relating to specific information disclosed.
The findings include:
On March 14, 2012, one client record requiring documentation of compliance with 4 Pa. Code 255.5 was reviewed. The facility failed to adhere to the limitations imposed at 4 Pa. Code subsection 2.55.5 (b) in one of one client records.
Client # 4 was admitted to the program on 12/14/11, and is a current client. Two signed "Consent for the Release of Confidential Information" forms were documented on 12/14/11. The two signed "Consent for the Release of Confidential Information" forms adhered to the limits imposed by 4 Pa. Code 255.5, but the facility released the results of the client's urinalysis tests to a government agency which exceeds the limitations imposed at 4 Pa. Code subsection 255.5(b). The release of the urinalysis results was documented on the Progress Report for December 2011.
The project director and clinical supervisor confirmed the findings.
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Plan of Correction
A review of 4 Pa. Code subsection 255.5 (b) and 42 CFR Part 2, Subpart C, subsection 2.31 was made by the Program Director and Clinical Supervisor.
The Clinical Supervior made appropriate changes to the judicial form that is completed when charting progress of clients in the forensic system. UDS result report has been removed from this form and replaced with a brief yes or no relapse statement which complies with 4 Pa. Code subsection 255.5(b).
The Clinical Supervisor and Program Director will complete a staff training on 4/18/12 and provide certificates to ensure staff are compliant with these changes to protect client confidentiality.
The forensic report forms are submitted once monthly and will be reviewed by the Clinical Supervisor prior to their submission. |
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 facility's policy and procedures manual, the facility failed to document psychosocial evaluations in accordance with facility policy in four of eight client records.
The findings include:
The facility's 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."
On March 14, 2012, eight client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document a psychosocial evaluation per facility policy in four of eight client records reviewed, # 1, 6, 7, and 8.
Client # 1 was admitted to the program on 2/3/12, and is still an active client.
The psychosocial evaluation was to be documented within thirty days of admission or by 3/3/12. However, at the time of review on 3/14/12 the facility failed to document a psychosocial evaluation for client # 1.
Client # 6 was admitted to the program on 12/1/11. The psychosocial evaluation was to be documented within thirty days of admission or by 1/1/12. The psychosocial evaluation was documented; however it did not include a completion date. In addition, the psychosocial evaluation was not evaluative as the facility provided a list of the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors, but did not evaluate the impact of those issues on this recovery effort. Furthermore, the psychosocial evaluation failed to document the counselor's conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 7 was admitted to the program on 1/25/12. The psychosocial evaluation was to be documented within thirty days of admission by 2/25/12. The psychosocial evaluation was documented; however it did not include a completion date. In addition, the psychosocial was not evaluative as the facility provided a list of the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors, but failed to assess the impact of those issues on this recovery effort. Furthermore, the psychosocial evaluation failed to document the counselor's conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 8 was admitted to the program on 2/3/12. The psychosocial evaluation was to be documented within thirty days of admission by 3/3/12. The psychosocial evaluation was documented; however it did not include a completion date. In addition, the psychosocial was not evaluative as the facility provided a list of the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors, but failed to assess the impact of those issues on this recovery effort. Furthermore, the psychosocial evaluation failed to document the counselor's conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The clinical supervisor confirmed the findings.
This is a repeat citation.
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Plan of Correction
The Clinical Supervisor and Program Director have revised the "Clinical Summary" section of bio-psychosocial assessments. In keeping with the format of the bio-psychosocial, required content is listed above the box where responses are to be typed.
The "clinical summary" now offers an open word box for clinicans to formulate a summary of their assessment for each individual client based upon their specific reports and needs.
Staff training will be conducted on 4/26/12 to ensure that staff are increasing their knowledge of the need for comprehensive clinical assessment within the bio-psychosocial document. Certificates will be issued following completion of this training.
The Clinical Supervisor or Program Director will review every completed bio-psychosocial at the time of its submission (within 30 days of intake). Clinicians will also conduct monthly quality assurance checks on random charts to ensure consistency in "clinical summary" completion.
For Client #1, the psychosocial evaluation was completed but not filed. This evaluation has been filed. Weekly random chart reviews will be completed by the clinician, clinical supervisor and program director to ensure all clinical documentation is filed correctly.
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