INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8 & 9, 2009 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 November 18, 2009.
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a tour of the physical plant, the facility failed to insure that hot water temperatures did not exceed 120 degrees Fahrenheit.
Findings:
A physical plant tour was conducted on October 9, 2009 at 4:15 PM. Hot water temperature readings were taken in 2 of 3 bathrooms and revealed temperatures at 125 and 129
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Plan of Correction
On 10/10/09 a temperature adjustment was made to the GPASS hot water heater. On
10/12/09 hot water temperature readings were taken in all 3 bathrooms and the results were that the 3 temperatures ranged between 114- 118 degrees Fahrenheit.
Temperature readings will schedule at least every 90 days and taken in all 3 bathrooms to insure the hot water temperatures did not exceed 120 degrees Fahrenheit.
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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.
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Observations
Based on a tour of the physical plant, the facility failed to ensure that exits from interior rooms and from the building are unobstructed from egress.
Findings:
A physical plant tour was conducted on October 9, 2009 between the hours of 4:15 PM and 5:00 PM. The second means of egress from the first floor is through a conference room that can be locked against egress or a staff bathroom that can be locked. The second exit from the basement discharges into the first floor file room where the exit door to the outside has a hasp and can be locked against egress.
This was confirmed by the facility director.
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Plan of Correction
On 10/16/09- non locking hardware was placed on the interior rooms doors to ensure that exits from interior rooms and from the building are unobstructed from egress.
The exit door in the file room to outside had the hasp was removed which allowed unobstructed from egress from the building.
Photos of the interior rooms doors hardware and exit door to the outside with the hasp removed were e-mailed to Gary Stauffer.
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on the review of personnel records, the facility failed to ensure that job descriptions contained written tasks and responsibilities of the position.
Findings:
A review of personnel files was conducted on October 9, 2009. The written job description of the Project Director stated that duties and responsibilities may be added, deleted or changed at times by the Board of Directors either verbally or in writing. Duties and responsibilities of the Project director must be described in writing and included in the job description.
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Plan of Correction
GPASS Faxed Gary Stauffer written job descriptions for project position which contained written tasks and responsibilities of the position.
Title changes were made
Executive Director /Project Director stated that duties and responsibilities may be added, deleted or changed at any times by the Board of Directors in writing only. A letter was Faxed to Gary Stauffer regarding the changes
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and interviews with staff, the facility failed to secure client records within locked storage containers.
Findings:
A physical plant tour of the facility was conducted on 10/9/09 at 4:15 PM. The active client records were stored on the first floor in cabinets that did not lock in an unlocked office.
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Plan of Correction
0n 10/23/09 an automatic door lock was installed in the door of the active client records office. The office will be locked at all times even when the record clerk is in the office. |
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 the review of client records, the facility failed to ensure that individual treatment and rehabilitation plans were developed for each client.
Findings:
A review of three active client records was performed on 10/9/09. The record of client # 1 whose admission date was 7/15/09 did not contain a treatment plan.
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Plan of Correction
The record of client # 1 whose admission date was 7/15/09 was found properly dated and entered into the record.
However, to ensure that to ensure that individual treatment and rehabilitation plans were developed for each client a GPASS created and implemented a compliance sheet that will assist the counselor in keeping track of due dates for Tx plans. In addition this the already procedures for Tx will be strictly enforced.
1). A preliminary treatment must be done at intake.
2). TX plans must be completed on or before due dates.
3). All TX plans will be placed in a folder on the GPASS server- so the TX plans can access and reviewed by the clinical supervisor, Leader counselor for compliance.
4. Disciplinary action will be taken if the counselor (s) fails to follow the procedure stated above.
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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 the review of client records, the facility failed to document timely follow up information where required.
Findings:
A review of three discharged client records was performed on 10/9/09. There was no documentation of a follow up contact in record #5 where the discharge date was 5/13/09. The record of client #4 documented a follow up contact on the day of the client ' s discharge. Facility policy requires that follow up contact be made within 30 days after discharge.
This was confirmed by the facility director.
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Plan of Correction
GPASS has a follow-up policy requires that follow up contact be made within 30 days after discharge.
GPASS maintains data base of all discharged clients which indicates the date of discharge and date that the client must be contacted to comply with GPASS policy. After the 30 day contact follow-up has been made the counselor is to enter the date of contact into the data base of discharged clients
A blank 30 day contact follow-up note was created to especially for this contact, which can be accessed by each counselor.
Disciplinary action will be taken if the counselor (s) fails to follow the 30 day Follow-up -contact policy.
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