INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15 through October 17, 2007 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 on December 10, 2007.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of employee records on 10/15/07 and an interview with the facility director on 10/17/07, the facility failed to document monthly meetings between the clinical supervisor and her supervisor for the first six months of her employment in the position of clinical supervisor.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of review of administrative and employee records on 10/15/07, the facility failed to document an assessment of staff training needs in nine of nine records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative records and an interview with the facility director on 10/15/07, the facility failed to document an overall training plan for the 2007/2008 training year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of employee records on 10/15/07, the facility failed to document employee feedback on completed training in two of three records reviewed, #1 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documents and an interview with the facility director on 10/15/07, the facility failed to document an annual evaluation of the overall training plan for the 2006/2007 training year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 training records on 10/15/07, the facility failed to document HIV/AIDS and TB/STD training hours for one of two employees reviewed, #1.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of training records on 10/15/07, the facility failed to document 12 training hours for the 2006/2007 training year in one of one record reviewed, #1.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on the physical plant inspection on 10/17/07, the second floor rear exit stairway was obstructed by the use of screening which was tied in two places on the stairway gate.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of employee records on 10/15/07, the facility failed to document that staff were instructed in the use of the fire extinguisher upon staff employment in five of nine employee records reviewed, #4, 5, 6, 7 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log on 10/17/07, the facility failed to document that unannounced fire drills were conducted at least once a month. Documentation that a fire drill was conducted was missing for 1/07, 2/07, 4/07, 5/07, 7/07 and 8/07.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of employee records on 10/15/07, the facility failed to document that personnel on all shifts were trained to perform assigned tasks during emergencies in eight of nine employee records reviewed, #1, 2, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill log on 10/17/07, the facility failed to document that a fire alarm or smoke detector was set off during each fire drill.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(d)(3) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(3) Describing the project's organizational structure.
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Observations
Based on a review of administrative documents, the facility failed to provide an organizational chart which clearly defines that the project director is responsible for reporting to the board for the entire project.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documents on 10/15//07, the project director failed to document goals and objectives which included available resources.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative documents on 10/15/07, the facility failed to document a written agreement for 24-hour emergency medical coverage.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of employee records on 10/15/07, the facility failed to provide documentation of salary information in nine of nine employee files reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of employee records on 10/15/07, the facility failed to document that individual staff performance was evaluated at least annually in three of four employee records reviewed, # 1, 4 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of employee records on 10/15/07, the project director failed to demonstrate that staff were informed of employee rights in nine of nine employee records reviewed, #1, 2, 3, 4, 5, 6, 7. 8 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Based on a review of administrative documents and employee records on 10/15/07, the facility failed to document that the requisite skills, knowledge and experience were included in job descriptions for nine of nine employee records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the licensing specialist's observation of reception area procedures on 10/15/07, the facility failed to provide for the confidentiality of client identity as evidenced by the front desk sign-in book which was placed on the counter for each client to sign upon arriving for appointments. This book is left lying on the counter and each subsequent client can see the names (first and last) of all clients who have signed the book.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c) 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:
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Observations
Based on a review of client records on 10/16/07 and 10/17/07, the facility failed to comply with 42 C.F.R., Part 2, Subpart E, subsection 2.63, and failed to obtain an informed and voluntary consent from the client in nine of nine client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9. Clients signed a Consent to Treatment form which included language that allowed the facility to disregard confidentiality in releasing information for probation and parole for "homicidal or suicidal threats, behavior or ideation" and "activities contrary to court stipulation". This form also included language that waived confidentiality if "homicidal or suicidal behavior is apparent". Additionally, clients signed a Rights and Responsibilities form which included language which allowed an exception to written consent "when records are required by your insurance company in order to gain continued authorization for services at SAFE".
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 on 10/16/07 and 10/17/07, the facility failed to obtain an informed and voluntary consent in five of nine client records reviewed, #1, 3, 5, 6 and 8. The specific information to be disclosed on consent to release forms to CBH was identified as "other" with nothing documented in the blank in two of nine records, #1 and 6. The specific information to be disclosed on consent to release forms to probation and parole was identified as "other" with nothing documented in the blank in two of nine records, #3 and 5. The specific information to be disclosed on consent to release form for "welfare" was identified as "other" with nothing identified in the blank in one record, #6. The specific information to be disclosed to probation was identified as "other" with "random drug screen" documented in the blank in one record, #5. The specific information to be disclosed to CBH was left blank for #8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records on 10/16/07 and 10/17/07, the facility failed to identify the purpose of disclosure in three of nine client records reviewed, #2, 3 and 9. Consent to release forms to DUI administration did not identify the purpose of disclosure in record #2. The consent to release form to probation did not identify the purpose of disclosure in record #3. The consent to release form to a Judge did not identify the purpose of disclosure in record #9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on a review of administrative policy on 10/15/07, the project director failed to ensure the client's right to inspect his own record as evidenced by language in policy which adds that the right to inspect is granted "if the Program Administrator approves the request".
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on 10/16 and 10/17/07, the facility failed to document a complete drug and alcohol history in nine of nine client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9. The substances abused was missing in seven of nine records, #1, 2, 3, 4, 5, 8 and 9. The length and patterns of use was missing in eight of nine records, #1, 2, 3, 4, 5, 6, 7 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records on 10/16 and 10/17/07, the facility failed to document a complete personal history in nine of nine client records reviewed. A personal history was not documented for client #3. Employment information was missing in eight records, #1, 2, 4, 5, 6, 7, 8 and 9. Education information was missing in six records, #1 4, 5, 6, 7 and 9. Military information was missing in five records, #1, 2, 6, 7 and 9. The sexual history was missing in six records, #1, 2, 5, 6, 7 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 on 10/16 and 10/17/07, the facility failed to document a complete psychosocial evaluation in nine of nine client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9. A psychosocial evaluation was not completed in two records, #3 and 4. Client problems and needs were not clinically evaluated in six records, #1, 2, 5, 6, 8 and 9. Assets/strengths and support systems were not evaluated in six records, #1, 2, 5, 6, 7 and 9. Coping mechanisms were not assessed in five records, #1, 5, 6, 8 and 9. Negative factors that may inhibit treatment and the client's attitude towards treatment were not evaluated in six records, #1, 2, 5, 6, 8 and 9. Counselor impressions and conclusions were not included in five records, #1, 2, 5, 6 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records on 10/16 and 10/17/07, the facility failed to document goals with measurable criteria in eight of nine client records reviewed, #1, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on 10/16 and 10/17/07, the facility failed to document a complete treatment plan update in four of five client records reviewed, #1, 4, 7 and 8. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records on 10/16 and 10/17/07, the facility failed to document complete progress notes in eight of nine client records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8. The plan section did not indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records on 10/16 and 10/17/07, the facility failed to document case consultations within the required timeframe in five of five client records reviewed, #1, 4, 6, 7 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records on 10/17/07, the facility failed to document follow-up information in five of five client records reviewed, #8, 9, 10, 11 and 12.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |