INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 25 and 26, 2008 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 October 28, 2008.
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Plan of Correction
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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.
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Observations
Based on a review of eight personnel records on September 24, 2008, the facility failed to document an individual training plan in two of four personnel records where required.
Findings:
The facility did not document an individual training plan for the 2008/2009 training year in personnel records #1 and 8.
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Plan of Correction
The Facility Director will correct the deficiency by having all staff and Facility Director complete and document all individual training plans in staff orientation. The Facility Director will be responsible for completing and documenting individual training plans. The Facility Director will monitor and review individual training plans on a monthly basis to ensure individual training plans are complete and documented in the appropriate time frame and in the personnel record.
The Facility Director will be responsible for ensuring that an individual training plan for each employee will be completed annually according to the policy and timeframes indicated in the agency.
The Facility Director shall present the completed individual training plans in supervision with Project director to document that the individual training plans are complete to ensure this deficiency does not recur
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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 provide documentation that the 2006/2007 annual report was made available to the public by December 31, 2007.
Finding:
The facility documented that the 2006/2007 annual report was made available to the public on 3/27/08.
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Plan of Correction
Plan of Correction:
GPASS fiscal year ranges from July 1-June 30. The Project Director will directly with the accountant to ensure that the annual report is completed by June 30 of that annual year. The Project Director will make sure to begin the process during the month of May and folow a month to month time-table to ensure he annual report will be available to the public six months after the end of the fiscal which would 12/31/08, the Project Director will make sure the annual report is make available to the public by December 31 of each year
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709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on a review of administrative documentation, the facility failed to document a financial statement of income and expenses in the 2006/2007 annual report.
Finding:
The facility's annual report for 2006/2007 did not include a financial statement of income and expenses.
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Plan of Correction
The Project Director will work directly with auditors/accountant each year. Each year the Project Director is responible for reviewing the annual report to ensure the annual report to the public includes a brief financial statement of income and expenses to ensure this deficienct does not reur. |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of administrative documentation, the facility failed to document in the 2006/2007 annual report a statement disclosing the names of the board of directors.
Finding:
The 2006/2007 annual report did not include a statement disclosing the names of the board of directors.
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Plan of Correction
The Project Director is responsible for updating and reviewing the names of and directors of the board on a monthly basis.
The Project Director is responsible for including a statement disclosing the names of the board of directors 2007/2008 annual report annual report and all subsequent reports thereafter to ensure this deficiency does not recur
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the facility failed to provide documentation that the fiscal audit for 2006/2007 was completed by 12/31/07.
Finding:
The facility documented the completion of the 2006/2007 annual audit on 1/17/08.
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Plan of Correction
The Project Director has obtained the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The Project Director will ensure that an audit scheduled before end of fiscal year(June 30). The Project Director will ensure the audit is completed within six months of the end of the fiscal year or at the latest December 31.
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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 upon a review of eleven client records on September 25 and 26, 2008, the facility failed to ensure that an informed and voluntary consent to release information was obtained in six of seven applicable client records reviewed.
Findings:
The specific information to be disclosed on the consent to release information form to the probation officer exceeded that allowed under the limitations imposed by 4 Pa. Code 255.5 in client record #1, 2, 3, 4, 5 and 6. The specific information to be disclosed included vital signs, medications, lab results, mental status and treatment history.
The specific information to be disclosed on the consent to release information form to CBH exceeded that allowed under the limitations imposed by 4 Pa. Code 255.5 in client record #1, 2, 4 and 5. The specific information to be disclosed included vital signs, medications, lab results, mental status and treatment history.
Additionally, the specific information to be disclosed on the consent to release information form to the probation officer was not specified in client record #7.
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Plan of Correction
The Project Director and Facility Director revised the voluntary consent to release information including the probation officer and CBH consent to release information contained in the client record to adhere to limitations imposed by 4 Pa. Code 255.5 The sections vital signs, medications, lab results, mental status and treatment history were entirely removed from the above mentioned forms
The revised forms were reviewed, accepted and forms went into effect as of 10/01/08. The old forms were purged from the computer system and all the old form were confiscated from counselors. The Facility Director immediately supplied the counselor's with the revised forms and instructions how the forms were to be completed.
Facility Director/Clinical supervisor will perform chart reviews and discuss the results of the reviews in supervision as it pertains to the revised forms on a week basis to ensure the revised forms are being used and completed correctly.
In addition, the Facility Director will ensure specific information to be disclosed on the consent to release information forms to the probation officer will be specified in client's record by reviewing client records on a weekly basis also in supervision
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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 eleven client records on September 25 and 26, 2008, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of seven applicable client records reviewed.
Findings:
The facility did not document the purpose of disclosure in consent to release forms for the probation officer in client record #1, 2, 4 and 5.
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Plan of Correction
The Project Director and Facility Director revised the voluntary consent to release information including the probation officer to adhere to limitations imposed by 4 Pa. Code 255.5 The sections vital signs, medications, lab results, mental status and treatment history were entirely removed from the above mentioned forms
The revised forms were reviewed, accepted and forms went into effect as of 10/01/08. The old forms were purged from the computer system and all the old form were confiscated from counselors. The Facility Director immediately supplied the counselor's with the revised forms. Facility Director instructed the counselor how to document the purpose of disclosure in consent to release forms for the probation officer in client record
Facility Director/Clinical supervisor will train new staff in orientation and have ongoing training regarding the proper method of filling out these forms. Facility Director/Clinical Supervisor perform chart reviews and discuss the results of the reviews in supervision as it pertains to the revised forms on a week basis to ensure the revised forms are being used and completed correct
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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 eleven client records, the facility failed to document psychosocial evaluations with the counselor's evaluation of the client's support system, negative factors that may inhibit treatment and the client's assets/strengths in five of seven applicable client records reviewed. Two psychosocial evaluations were missing entirely.
Findings:
The facility did not document complete psychosocial evaluations in client record #1, 2, 3, 4 and 6. Additionally, in client record #5 and 7 a psychosocial evaluation was not documented at all.
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Plan of Correction
The Facility Director/Clinical supervisor completed psychosocial evaluations in client record #1, 2, 3, 4 and 6. Additionally, in client record #5 and 7 a psychosocial evaluation will be documented.
The Facility Director/Clinical supervisor will emphasis the importance of biopsychosocial clinical summary during initial trainings and orientations of all staff.
Facility Director/Clinical Supervisor will provide ongoing training and training as needed in regards of the biopsychosocial clinical summary. The psychosocial evaluations with the counselor's evaluation will reviewed in weekly supervision by to ensure compliance to the policy for completing biopsychosocial clinical summaries. The biopsychosocial clinical summary revised 10/01/08 to reflect the client's support system, negative factors that may inhibit treatment and the client's assets/strengths identifies, coping mechanisms and attitude toward treatment. The Facility Director/Clinical supervisor will be responsible for pursuing corrective actions when the biopsychosocial are not complete or when
Psychosocial evaluations were missing entirely.
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709.92(a) 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:
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Observations
Based on a review of eleven client records on September 25 and 26, 2008, eight client records were required to have comprehensive treatment plans. The facility failed to document a comprehensive treatment plan for four of eight client records reviewed.
Findings:
The facility failed to document a comprehensive treatment plan for client record #1, 6, 7 and 8.
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Plan of Correction
The Facility Director will have expert trainers from outside of in the agency train and instruct the clinical staff on compensative training plans at least twice per year. The Facility Director in initial trainings and orientations will provide in depth trainings regarding comprehensive treatment training plans.
The Facility Director/Clinical Supervisor will provide ongoing instruction and training regarding comprehensive treatment training planning in individual and group supervisions
Facility Director/Clinical Supervisor will perform chart reviews a weekly basis and random audit focused on the quality of the comprehensive treatment plans. The results of these chart review and audit will be discussed in weekly supervision and group supervision to ensure this deficiency does not recur.
The failure to document and/or properly complete comprehensive treatment plans will result in disciplinary action.
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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 eleven client records on September 25 and 26, 2008, the facility failed to document the treatment plan goals in terms of measurable criteria in two of four client records where a comprehensive treatment plan was required.
Findings:
The facility did not document treatment plans with goals that were stated in measurable criteria in client record #2 and 5.
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Plan of Correction
The Facility Director/Clinical Supervisor will provide instruction on the necessity of the comprehensive treatment plan that includes short and long-term goals treatment plan goals in terms of measurable criteria for treatment The treatment plan will be formulated by both staff and client. Facility Director/Clinical Supervisor in initial trainings and orientations of all staff will provide instruction on how to complete comprehensive treatment plan that includes short and long-term goals treatment plan goals in terms of measurable criteria.
The Facility Director/Clinical Supervisor will provide ongoing trainings and as needed training and instruction regarding comprehensive treatment plan with measurable criteria.
The Facility Director/Clinical Supervisor will monitor and review charts weekly for proper treatment Plan completion. The treatment plan will be reviewed and discussed in individual on a weekly basis and group supervision as scheduled to ensure that the deficiency regarding treatment plan short and long-term goals treatment and measurable criteria for does not recur. .
The failure to include short and long-term goals treatment plan goals in terms of measurable criteria for treatment will result in disciplinary action.
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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 six client records where follow-up was due, the facility failed to document follow-up in four of six client records.
Findings:
The facility did not document follow-up in client record #6, 7, 8 and 9.
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Plan of Correction
Facility Director/Clinical Supervisor will be responsible to ensure that follow-up will be performed and documented when due.
Facility Director/Clinical Supervisor
Is responsible for maintaining a list of all discharge clients and the client's date for follow-up contact. The follow-up list will be provided to the therapist by the Facility Director/Clinical.
The Facility Director/Clinical Supervisor will monitor and review the follow-up contact list for compliance. The follow-up contact list will be reviewed and discussed in individual on a weekly basis and group supervision as scheduled to ensure that the deficiency regarding failed to documentation follow-up for does not recur
The failure to document follow-up in client record will result in disciplinary action.
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