INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4-5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPASS-Asian Outpatient Counseling Serv. 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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704.11(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 personnel and training records, the facility failed to provide documentation of HIV/AIDS training in one of five applicable records reviewed
The findings include:
Five personnel records which required documentation of mandatory communicable disease training were reviewed on September 5, 2013. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee #4 was hired 1/23/12 as a counselor. This employee was required to obtain six hours of HIV/AIDS the training by 1/23/13. Employee #4 failed to obtain the training as of the date of the inspection.
The Facility Director confirmed the findings.
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Plan of Correction
The Facility Director has reviewed state regulation regarding communicable diseases and has suspended employee #4 until HIV/AIDS training is completed. Employee #4 has been registered for HIV training on 10/16/13.
To ensure this deficiency does not occur again, the Facility Director will conduct quarterly reviews of all clinician personnel records to ensure state training regulations are met in a timely fashion.
The Facility Director and Lead Clinician will be responsible for all staff training plans and scheduling. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, the facility failed to make available to the public their annual report.
The findings include:
On September 4-5, 20013, the facility's administrative documentation was reviewed. The facility was required to make an annual report available to the public.
The 2012 annual report was completed 7/31/13 and reviewed during the inspection; however, the facility failed to verify how the annual report was made available to the public. The Facility Director stated that the report is put on their website but it was not listed on the website as of the time of the inspection.
The Facility Director confirmed the findings.
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Plan of Correction
The Facility Director and Assistant Director have reviewed company website access information and coding and filed an announcement of the annual report's availability on the company's homepage.
To ensure this deficiency does not occur again, the Facility Director will update the company's website at the beginning of each fiscal year to announce availability of annual report. |
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, the facility failed to document an individualized psychosocial evaluation in five of nine applicable records reviewed.
The findings include:
Nine client records which required documentation of an individualized psychosocial evaluation were reviewed September 4-5, 2013. Client records # 2, 3, 6, and 7 contained identical psychosocial evaluations. Client record # 4 did not contain documentation of a psychosocial evaluation.
Client # 2 was admitted on 6/27/13. The psychosocial evaluation was completed on 7/10/13 and was identical to the psychosocial evaluations included in client records # 3, 6, and 7.
Client # 3 was admitted on 6/18/13. The psychosocial evaluation was completed on 7/10/13 and was identical to the psychosocial evaluations included in client records # 2, 6, and 7.
Client # 4 was admitted on 7/3/13. This client record did not contain documentation of the completion of a psychosocial evaluation as of the date of the inspection.
Client # 6 was admitted on 7/3/13. The psychosocial evaluation was completed on 7/15/13 and was identical to the psychosocial evaluations included in client records # 2, 3, and 7.
Client # 7 was admitted on 2/21/13. The psychosocial evaluation was completed on 2/21/13 and was identical to the psychosocial evaluations included in client records # 2, 3, and 6.
The Facility Director confirmed the findings.
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Plan of Correction
The Facility Director and Quality Assurance Committee have reviewed psychosocial documentation and revised the clinical summary section of the psychosocial that was identical across multiple records.
The new clinical summary no longer features a template that can be easily used without revisions.
For records 2, 3, 6, and 7, an individualized clinical summary addendum has been added to the psychosocial evaluation.
To ensure this deficiency does not occur again, the Facility Director now leads the Quality Assurance Committee in weekly reviews of random clinical records to ensure individuality and accuracy in record keeping. |