INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 23, 2018 by staff from the Division of Drug and Alcohol 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:
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Seven personnel records were reviewed for the documentation of an individual training plan on October 23, 2018. The facility failed to document an individual training plan for personnel records # 7 and 8.
Employee # 7 was hired by the facility on December 20, 2016 and is employed in the DUI specialist position.
Employee # 8 was hired by the facility on April 1, 2008 and is employed in the office manager position.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Effective 11/15/18, Program has remedied these deficiences of identified staff members. The Training Plans were reviewed and signed by staff. To ensure this deficiency does not recur, the Program Director has developed and implemented a Staff Training spreadsheet which will be reviewed bi-weekly to ensure appropriate documentation has been completed. The Office Manager of Human Resources department will monitor and review monthly. |
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.
|
Observations
Two personnel records were reviewed for the project director and facility director positions on October 23, 2018. The facility failed to document the completion of at least 12 annual training hours for employee # 1.
Employee # 1 has been employed in the project director position since June 24, 2013. This employee's record contained no documentation of completed annual training hours for the July 1, 2017 - June 30, 2018 training year.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Facility/Project Director failed to complete the required annual, 12 hours of Training from July 1, 2017 - June 30, 2018. Effective, 12/1/18, to ensure this deficiency does not recur. The Facility/Project Director's annual training requirements will be added to the staffing spreadsheet and reviewed monthly by Program Director to ensure completion of training hours from July 1, 2018, to June 30, 2019. The Human Resources Manager will monitor and review monthly. |
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.
|
Observations
A physical plant inspection was conducted on October 23, 2018. In the rear of the facility, the back egress (a gate) was observed to be padlocked. Therefore, the facility failed to ensure that this exit was unobstructed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Effective 10/24/18, this deficiency has been remedied. All staff members were trained and instructed not to have the gate locked during business hours. A checkoff sheet was created and will be completed several times a day by maintenance staff to ensure all exits clear from any obstruction. The Program Director will review and monitor to ensure complaince. |
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.
|
Observations
Seven client records were reviewed on October 23, 2018. The facility failed to obtain an informed and voluntary consent to release information for client record # 7.
Client # 7 was admitted into treatment on February 19, 2018 and was discharged on July 23, 2018. A consent to release information to the client's treatment funding source, an insurance company, was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Effective 10/24/18 all staff members were trained and instructed on the completion of Informed Consents. To ensure this deficiency does not recur, the Program Director has developed and implemented a plan in which all charts will be audited at the time of Intake. Staff Members will complete the Chart Audit Checklist Form, to ensure appropriate documentaion has been completed by client and placed in the client's chart. A random chart audit will be conduct monthly by the Program Director to ensure compliance. |