INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Greater Philadelphia Asian Social Service Center-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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations, which shall be reviewed and signed by the employee, in three of four applicable personnel records reviewed.Employee #3 was hired as a counselor on January 13, 2020.Employee #4 was hired as a counselor on March 18, 2020.Employee #5 was hired as a counselor on December 17, 2019. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director/Facility Director (P/FD) provided the Clinical Supervisor (CS) with training on how to complete annual written individual staff performance evaluations (PE) to include employee review and signature on 10/25/2021. The CS will complete PEs with staff annually, including their review and signature and will ask the P/FD for assistance any time she has a question or concern. The P/FD will provide the CS with additional training as needed. The P/FD will review all PEs as they are completed to assure employees were provided the opportunity to review and comment on their PEs as supported by their signatures. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of seven client records reviewed. Client #2 was admitted on August 12, 2021 and was still active at time of inspection. The client's treatment and rehabilitation plan was dated September 15, 2021 and indicated that the client was to receive two individual sessions per week and one group session per week. There was no documentation in the record of any individual sessions or group sessions provided to the client since September 28, 2021.Client #3 was admitted on July 20, 2021 and was still active at time of inspection. The client's treatment and rehabilitation plan was dated August 20, 2021 and indicated that the client was to receive two individual sessions per week and one group session per week. There was no documentation in the record of any individual sessions or group sessions provided to the client since October 1, 2021.Client #4 was admitted on June 4, 2021 and was still active at time of inspection. The client's treatment and rehabilitation plan was dated August 31, 2021 and indicated that the client was to receive two individual sessions per week and one group session per week. There was no documentation in the record of any individual sessions or group sessions provided to the client since October 1, 2021.Client #5 was admitted on December 16, 2019 and was discharged on September 13, 2021. The client's treatment and rehabilitation plan was dated July 14, 2021 and indicated that the client was to receive one individual session per week. There was no documentation in the record of any individual sessions provided to the client since July 28, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual and group progress notes for all clients were completed by assigned
counselors in timely fashion. However, they were not filled in client charts until 10/29/2021 because the agency's practice has been to bill sessions before filing notes. As of 11/1/2021 this practice has changed. All notes and other client documents are directly entered into OPUS, GPASS' new EMR by each counselor. Both the CS and the P/FD have administrative rights to OPUS that allows them to review all documentation submitted. They will do so monthly to assure all notes are completed in OPUS in timely fashion.
During the clinical staff meeting on 10/28/2021, the CS provided the counseling staff with additional training in how to and the importance of regularly following up with clients to assure that they keep their appointments as scheduled in compliance with their individual treatment/recovery plans. Staff will ask the CS for assistance any time they would like additional training. The CS will review EMR client charts during weekly individual supervision, including treatment plans and progress notes to assure staff are regularly following-up on client attendance in keeping with treatment/recovery plans. The P/FD will review EMR client charts monthly to further assure staff are regularly following-up with clients and documenting their effort on progress notes. |