INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 8 & 9, 2010 licensure renewal inspection. The follow-up inspection was conducted on March 18, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, GPASS-Asian Outpatient Counseling Services 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 April 13, 2010.
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Plan of Correction
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour on March 18, 2010, the facility failed to permit in the facility heaters that are not permanently mounted or installed.
The findings include:
During the on-site investigation, conducted on March 18, 2010, two heaters that were not permanently mounted or installed were located in the facility.
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Plan of Correction
The facility will not allow any heaters that are not permanently mounted or installed. The facility will be inspected on a regular basis for any heaters that are not permanently mounted or installed to insure this deficiency does occur again
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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.
The findings include:
Upon arrival to the facility on March 18, 2010 it was observed that the door, where the file cabinets were kept, was open and no one was in the office. During the physical plant tour conducted on the same day it was told by staff that active client records are located in this office and that the file cabinets are not locked so the confidentiality of the clients are not secured within locked storage containers.
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Plan of Correction
The door, where the file cabinets are kept will be closed and locked while not in use. Locks were installed on each file cabinet that contains clients record. The file cabinets file have individual locks on each cabinet and these will be locked file cabinets while not in use.The record keeper has the key to access File cabinets that contains client's records. Therefore, clients record are in locked storage containers which will ensure the deficiency will not occur again.
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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 the review of client records, the facility failed to ensure that individual treatment and rehabilitation plans were developed for each client in two of eight client records.
The findings include:
Eight client records were reviewed on March 18, 2010. Treatment and rehabilitation plans were required in six client records. Client records #6 and 8 did not have documentation of a client treatment plan. In accordance facility policy and procedure, the facility has 30 days of a client's admission to complete a treatment plan.
Client #6 was admitted on 11/6/09 and discharged on 1/22/10. The treatment plan was required to be developed by 12/6/09; there was no documentation of a treatment plan in the client record.
Client #8 was admitted on 12/29/09 and discharged on 2/8/10. The treatment plan was to be developed by 1/29/10; there was no documentation of a treatment plan in client record.
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Plan of Correction
The has facility implemented a new practice and procedure to ensure that individual treatment plans will be 30 days of admission for each client. Each Therapist has a compliance sheet that indicates the date for comprehensive treatment plan to be completed. The program director and chart review committee reviews the clients records for per GPASS policy and procedure for completion of for comprehensive treatment plan. The therapist is alerted if the plan is out of compliance for correction. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in one of three client records reviewed.
The finding includes:
Eight records were reviewed on March 18, 2010. Treatment plan updates were required in three records reviewed. In accordance with facility policy and procedure, all treatment plans will be updated every 60 days after the comprehensive treatment plan. Client record #3 did not have documentation of clients treatment plan updates.
Client #3 was admitted on 11/25/09 and the comprehensive treatment plan was completed on 12/11/09 with no further documentation of updates.
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Plan of Correction
The has facility implemented a new practice and procedure to ensure that individual treatment all treatment plans will be updated every 60 days after the comprehensive treatment plan for each client. Each Therapist has a compliance sheet that indicates the date of the Update for comprehensive treatment plan The program director and chart review committee reviews the clients records for per GPASS policy and procedure for completion of Update for comprehensive treatment plan. The therapist is alerted if the plan is out of compliance for correction. |
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 follow-up information in accordance with facility policy in three of four discharged records reviewed.
The findings include:
Eight client records were reviewed on March 18, 2010. Follow-up information was required in four discharge records#5, 6, 7 and 8. In accordance with facility policy and procedure all follow-ups will be done within 30 days of clients discharge if not being referred.
Client #6 was admitted on 11/6/09 and discharged on 1/22/10; there is no documentation of a follow-up in the patient record.
Client #7 was admitted on 1/4/10 and discharged on 1/26/10; there is no documentation of a follow-up in the patient record.
Client #8 was admitted on 12/29/09 and discharged on 2/8/10; there is no documentation of a follow-up in the patient record.
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Plan of Correction
A binder is being kept that contains the names of all discharged clients and clients referred to another facility for treatment. The binder contains the date of discharge, 30-days follow-up contact date for all discharged clients. Clients referred to another facility for treatment will have 7 days from referral date or appointment date to have a a follow-up contact which is also being kept in the binder. The binder will reviewed on a weekly basis to ensure this deficiency does not occur. |