INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5 & 6, 2010 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 September 7, 2010.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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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 inform the client, in writing, of a decision to involuntarily terminate the client's treatment.
The findings include:
The facilities policy states:
A notice/letter of termination will be sent to the listed address of every client who fails to comply with the facilities rules of conduct, non-compliance with treatment policies, and or failure to keep scheduled appointment.
The client will have 72 hours to respond to this letter.
Two closed client records were reviewed on August 6, 2010.
One client record required notification of termination.
The facility failed to document a notification of termination in client record # 7.
Client # 7 was admitted to the facility on 1/21/10; and discharged on 6/1/10 for non-compliance.
At the time of review on August 6, 2010 the facility failed to document a notification of termination.
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Plan of Correction
GPASS made a notification termination and documented notification termination termination in client # 7 record for non-compliance that allowed the client 72 hours to respond to this letter.
To insure this deficiency does not occur again a Discharge Case Conference for for non-compliance must be held before the the facility can inform the client, in writing, of a decision to involuntarily terminate the client's treatment (Intent to Close Notice). An Intent to Close Noice Must be dated and documented in the the client's record. The clincial supervisor/ Program director will attend the Discharge Case Conference. The clincial supervisor/ Program director will sign-off the (Intent to Close Notice) and insure a copy of the notice is in the client's record. The Intent to Close Notice is part the Clinical Chart reveiw sheet that the Clincial supervisor/ Program director utilizes to review records for compliance.The Clincial supervisor/ Program director reviews each client's record that a decision to involuntarily terminate the client's treatment has been made. The Clincial supervisor/ Program director checks the record for Intent to Close Notice is in the record. In case that this procedure is not followed corrective actions will be taken. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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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 give the client an opportunity to request reconsideration of a decision to terminate treatment.
The findings include:
The facilities policy states:
A notice/letter of termination will be sent to the listed address of every client who fails to comply with the facilities rules of conduct, non-compliance with treatment policies, and or failure to keep scheduled appointment.
The client will have 72 hours to respond to this letter.
Two closed client records were reviewed on August 6, 2010.
One client record required documentation that the client was given an opportunity to request reconsideration of a decision to terminate treatment.
The facility failed to document that client # 7 was given an opportunity to request reconsideration.
Client # 7 was admitted to the facility on 1/21/10; and discharged on 6/1/10 for non-compliance
At the time of review on August 6, 2010 the facility failed to document that the client was given an opportunity to request reconsideration of a decision to terminating treatment.
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Plan of Correction
A notice of termination was created in order for the client #7 will have 72 hours to respond to this notice,
to request an opportunity to reconsideration of a decision to terminate treatment.
To insure that clients are given at least 72 hours to respond the Intent to Close Notice and have an opportunity to request reconsideration of a decision to terminate treatment for non-compliance. An Intent to Close Notice)will composed,reviewed & signed off by the Clincial supervisor/ Program director. The Clincial supervisor/ Program director will insure that Intent to Close Notices are dated and sent out to allow the client at least 72 hours to respond the Intent to Close Notice and the client have ample opportunity to request reconsideration of a decision to terminate treatment for non-compliance. The clincial supervisor/ Program director make sure that no client's case is discharged until at least 72 hours has elpased after the the notice is sent, which affords the client an opportunity to respond the Intent to Close Notice. A copy of the Intent to Close Notices will placed in the client's record.The Clincial supervisor/program director will review the record of non-compliance discharge and insure the notice/letter of termination is sent out to give the client 72 hours to respond to Intent to Close Notice. The Clincial supervisor/program director will check the record before disicharge for appropriately dated Intent to Close Notices. The clincial supervisor/program director will reinforce this procedure with the staff in individual and group supervisions/meetings. Th Clincial supervisor/ Program director In case that this procedure is not followed corrective actions will be taken. |
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 and a review of the facilities policy and procedures manual, the facility failed to document a drug or alcohol history.
The findings include:
The facilities policy states:
During the initial assessment, the assessor will need to start the psychosocial assessment. The psychosocial assessment is to be completed by the second or third visit or within 30 days of admission or readmission.
The psychosocial assessment will include but not limit to the following histories information:
medical history; family/social; drug and alcohol history; and their personal history, which includes sexual, recreation, educational, employment, financial, military, legal, psychiatric, and others where appropriate.
Five active client records were reviewed on August 6, 2010 for documentation of a drug or alcohol history.
The facility failed to document a drug or alcohol history within 30 days as per policy in one of five client records, specifically, client record # 2.
Client # 2 was admitted to the program on 5/6/10.
The drug or alcohol history is due 30 days of admission by 6/6/10.
The facility documented the drug or alcohol history on 6/11/10.
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Plan of Correction
The Bio-Psychosocial Assessment per GPASS policy will be completed within 30 days of admission. To ensure that this deficiency does not happen again, GPASS has instituted a Compliance Sheet - for the primary counselor to follow. The date the Bio-Psychosocial was started and the required completion date are noted on this Compliance Sheet. This sheet will be brought to individual supervision on a weekly basis and reviewed by the staff member and supervisor. The clinical supervisor or program director will ensure the Bio-Psychosocial is completed within the required 30 day period. Chart audits are completed on a regular basis to ensure that each clinical record is in compliance, which includes the Bio-Psychosocial. |
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 and a review of the facilities policy and procedures manual, the facility failed to document a personal history.
The findings include:
The facilities policy states:
During the initial assessment, the assessor will need to start the psychosocial assessment. The psychosocial assessment is to be completed by the second or third visit or within 30 days of admission or readmission.
The psychosocial assessment will include but not limit to the following histories information:
medical history; family/social; drug and alcohol history; and their personal history, which includes sexual, recreation, educational, employment, financial, military, legal, psychiatric, and others where appropriate.
Five active client records were reviewed on August 6, 2010 for documentation of a personal history.
The facility failed to document a personal history within 30 days as per policy in one of five client records, specifically, client record # 2.
Client # 2 was admitted to the program on 5/6/10.
The personal history is due 30 days of admission by 6/6/10.
The facility documented the personal history on 6/11/10.
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Plan of Correction
The Bio-Psychosocial Assessment per GPASS policy will be completed within 30 days of admission. To ensure that this deficiency does not happen again, GPASS has instituted a Compliance Sheet - for the primary counselor to follow. The date the Bio-Psychosocial Assessment/Personal History was started and the required completion date are noted on this Compliance Sheet. This Compliance sheet will be brought to individual supervision on a weekly basis and reviewed by the staff member and supervisor. The clinical supervisor or program director will ensure the Bio-Psychosocial Assessment/Personal History is completed within the required 30 day period. Chart audits are completed on a regular basis to ensure that each clinical record is in compliance, which includes the Bio-Psychosocial |
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.
The findings include:
The facilities policy states:
The psychosocial Evaluation must be completed within thirty days of admission to outpatient.
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:
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.
Conclusions regarding the client's attitude towards and ability to participate in the treatment process.
Five active client records were reviewed on August 6, 2010 for documentation of a psychosocial evaluation.
The facility failed to document a psychosocial evaluation within 30 days of admission as per policy in one of five client records reviewed, specifically, client records # 2. The facility failed to document a psychosocial evaluation to include the client's coping mechanisms other than drinking and to document the counselor's conclusions/impressions in one of five records reviewed, specifically, record #5.
Client # 2 was admitted to the program on 5/6/10.
The psychosocial evaluation is due within 30 days.
The facility documented the psychosocial evaluation on 6/11/10.
Client # 5 was admitted to the program on 3/30/10.
The facility documented the psychosocial evaluation on 3/30/10; however, the facility stated that drinking was the client's form of coping mechanism; in addition, the facility failed to documented the counselor's conclusions/impressions.
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Plan of Correction
Client# 2- The Bio-Psychosocial Assessment per GPASS policy will be completed within 30 days of admission. To ensure that this deficiency does not happen again, GPASS has instituted a Compliance Sheet - for the primary counselor to follow. The date the Bio-Psychosocial Assessment/Personal History was started and the required completion date are noted on this Compliance Sheet. This Compliance sheet will be brought to individual supervision on a weekly basis and reviewed by the staff member and supervisor. The clinical supervisor or program director will ensure the Bio-Psychosocial Assessment/Personal History is completed within the required 30 day period. Chart audits are completed on a regular basis to ensure that each clinical record is in compliance, which includes the Bio-Psychosocial
Client#5- The insure this deficency does not occur again, GPASS has revised the Clinical Summary Section of Bio-Psychosocial Assessment/Personal History. GPASS has enhanced and incorporated coping mechanisms, counselor's conclusions/impressions to be documented in this section. This section of the Bio-Psychosocial Assessment/Personal History will be reviewed and discussed in individual and group supervision on a weekly basis.The supervisor or program director will conduct ongioing training on documenting coping mechanisms counselor's conclusions and impressions. Client #5 has been dsicharged- |
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 and a review of the facilities policy and procedures manual, the facility failed to document a treatment and rehabilitation plan update at least every 60 days.
The findings include:
The facilities policy titled 'Treatment Plan Update' states:
The treatment plan is updated every 60 days.
Four active client records requiring treatment plan updates were reviewed on August 6, 2010.
The facility failed to document a treatment and rehabilitation update at least every 60 days in client record # 5.
Client # 5 was admitted to the program on 3/30/10 and the comprehensive treatment plan was documented on 4/30/10.
The treatment plan update is due within 60 days.
The facility documented the treatment plan update on 7/7/10.
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Plan of Correction
The GPASS can not correct deficiency for client #5, client #5 - stopped attending treatment and was discharged. However, to insure this deficiency does not happen in the future GPASS has taken several steps. (1) Each therapist has a Treatment Compliance Sheet. This sheet clearly indiciates the dates for completion of the comprehensive treatment plans and due dates treatment plans updates. (2) The clinical supervisor/program director as a copy of these compliance sheets for each therapist which allow clinical supervisor/program director to review the treatment plans due dates at any time. (3) The Treatment Compliance Sheet-treatment plans dates are discussed and reviewed in supervision. (4)Treatment Plans and Treatment Plan updates are placed on the GPASS server for easy access and immediate review and inspection by the clinical supervisor/program director.
(5) Clinical Chart reviews are being done by the clinical supervisor/program director and assigned staff on an ongoing basis. In case that the this deficiency is found in the future corrective will be taken. |
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 and a review of the facilities policy and procedures manual, the facility failed to document a complete client record.
The facilities policy titled 'Case Consultations' states:
Each client's case must be reviewed at least every ninety days, beginning with the first treatment plan update (i.e. three months after entering Outpatient services), or consultation, names or persons attending and their disciplines, name of client reviewed, summary of the discussion, and disposition of the case.
Four client records requiring case consultations were reviewed on August 6, 2010.
The facility failed to document a case consultation in client record # 5.
Client # 5 was admitted to the program on 3/30/10.
A case consultation is due three months after entering Outpatient services.
At the time of review on August 6, 2010 the facility failed to document a case consultation or complete client record.
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Plan of Correction
Case consultation was conducted for Client #5- 3 months after admission into Outpatient services.
GPASS To ensure that this deficiency does not ocurr again, has instituted Treatment Compliance Sheet. Each therapist has a Treatment Compliance Sheet that indicates the admission date and the due date of the Case Consulation for each client. The clinical supervisor/program director also has a copy of each therapist's Treatment Compliance Sheet to review at any time. Treatment Compliance Sheet in reviewed and discussed in supervision to alert the theraipist about upcomimg Case Consulations. The clinical supervisor/program director or assigned staff perform clinical chart audits/reviews to ensure Case Consulations completed three months after entering Outpatient services.
If Case Consulations are not completed three months after entering Outpatient services corrective actions will be taken
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