INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25, 2014 and August 26, 2014 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:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records reviewed.
The findings included:
Three clinical personnel records were reviewed on August 25, 2014. The facility failed to ensure that employee # 3 met the educational requirements for the position of counselor.
Employee #3 was hired as an associate's level counselor on Jan. 9, 2012. Employee #3 did not meet the qualifications for the position of counselor as they have an associate's degree with a major in "Liberal Arts General", which is not an approved major.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed 704.12 and re-titled clinician #3 to reflect her status as Counselor Assistant.
All documentation in clinician #3's personnel records have been amended to read "Counselor Assistant", this includes: Job Description, Employment Contract, and Supervisory Documents.
Clinical Supervisor completed an individual supervision session with Clinician #3 and it was determined that Clinician #3 will continue to receive weekly individual supervision and weekly team supervision, direct observation is not required at this time.
To ensure this deficiency does not reoccur, Program Director will review credentials for all new hires and compare these credentials to the requirements of 704.12. Those failing to meet the qualifications to be considered Counselor, will receive the title of Counselor Assistant and the necessary supervision. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in two of four personnel records reviewed.
The findings include:
Four personnel records which required documentation of mandatory communicable disease training were reviewed on August 25, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employees #1 and #2.
Employee #1 was hired on 10/8/12 as a counselor. Employee #1 was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by 10/8/13. The facility failed to ensure that employee #1 obtained the training as of the date of the inspection.
Employee #2 was hired 10/31/12 as a counselor. This employee was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by 10/31/13. The facility failed to ensure that employee #2 obtained the training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 9/5/2013 inspection.
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Plan of Correction
The Chief Operating Officer, a Registered Nurse in Pennsylvania, provided HIV/AIDS and TB/STD training to employees #1 and #2 in accordance with DDAP Licensing Alerts 1-97 and 6-97 on 9/22/2014.
To ensure this deficiency does not recur, a Registered Nurse or the Facility Medical Director will provide TB/STD and HIV/AIDS training to all newly hired staff within one month of hire date following the guidelines set forth in Licensing Alerts 1-97 and 6-97. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of three personnel records reviewed.
The findings included:
The facility's training year is from July 1 through June 30.
Three counselors' personnel records were reviewed on August 25, 2014. The facility failed to document the completion of 25 clock hours of annual training for employee #1.
Employee # 1 was hired on October 8, 2012 as a counselor. Employee # 1 only completed 17 clock hours of annual training for the July 2013 to June 2014 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 received an additional 10 hours of training ending on 9/22/2014.
Program Director will conduct monthly training reviews for all clinical personnel to ensure that relevant trainings have been identified and scheduled in order to satisfy DDAP requirements of 25 clock hours per training year.
The facility will continue to conduct relevant in-house trainings to supplement outside training opportunities. |
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 observation during a physical plant inspection, the facility failed to ensure that all exits from the facility were unobstructed.
The findings included:
A physical plant inspection was conducted on August 26, 2014 at approximately 10:50 AM.
The bottom landing of the fire escape ladder from the second floor in the rear of the facility was obstructed by a chair.
There was a pad lock hanging next to the gate exit in the rear of the building. The pad lock is used to lock the gate exit during the hours that the outpatient clinic is closed. The use of the pad lock obstructs egress from the gate exit in the rear of the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director completed a tour of the facility on 09/04/2014 and reviewed 705.28.
Signage reading "Keep Area Clear" was affixed to the area around the fire exit stairway and other means of egress around the facility.
Program/Facility Director will conduct daily tours of facility to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed. This includes a review that the rear gate remains unlocked between the hours of 830am and 800pm.
Upon opening the facility at 8:30am the Program Director will lock the rear gate's pad lock in the CEO's desk drawer which will require a key to access. The pad lock will only then be removed by the CEO upon the close of business operations each day.
An exception letter will be sent on 09/25/2014 to DDAP requesting that the rear lower gate of the facility be permitted to be locked outside of facility operating hours given the unsafe nature of the neighborhood surrounding said facility. It is to be noted that the facility was the victim of a previous break-in which prompted tighter security measures. This will be reflected in said exception request. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client rights forms, the facility failed to demonstrate that it informed clients of all of their rights in ten of ten client records reviewed.
The findings included:
The facility utilized a client rights form, signed by the client, to inform clients of their rights.
Ten client records were reviewed August 25 - 26, 2014. The facility failed to inform clients # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 of all their rights as the client rights forms contained in those records were missing the following information:
1) the right to appeal a decision limiting access to his/her records
2) the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his/her records
3) the right to submit rebuttal data or memoranda to his/her own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed 709.30 and compared the facility's current client rights form.
Program Director subsequently pulled required elements from 709.30 and entered the information into the facility's client rights form to ensure compliance. This revised form went into use on 9/5/2014.
To prevent this deficiency from recurring, Program Director will conduct monthly reviews of 709.30 and present current information to the Quality Assurance Team.
The Quality Assurance Team will then conduct weekly reviews of clinical records to ensure that the most up to date client rights form is being utilized and is appropriately signed. |
709.93(a) 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:
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Observations
Based on the review of the client records, the facility failed to document a complete client record in six of ten client records reviewed.
The findings included:
Ten client records were reviewed on August 25 - 26, 2014. The facility failed to document a complete record of service in client record #9 and failed to document progress notes for counseling sessions in client records #1, 5, 6, 8, 9 and 10.
Client #1 was admitted to treatment on 4/8/14. Per the record of services, the client attended individual counseling sessions on 8/1/14, 8/8/14, 8/15/14, and 8/22/14 and group counseling sessions on 8/14/14, 8/19/14, and 8/21/14. There were no progress notes completed for these counseling sessions.
Client #5 was admitted to treatment on 5/19/14. Per the record of services, the client attended individual counseling sessions on 8/18/14 and 8/21/14. There were no progress notes completed for these counseling sessions.
Client #6 was admitted to treatment on 4/24/14. Per the record of services, the client attended individual counseling sessions on 5/8/14 and 8/18/14 and group counseling sessions on 8/14/14 and 8/21/14. There were no progress notes completed for these counseling sessions.
Client #8 was admitted to treatment on 10/14/13. Per the record of services, the client attended group counseling sessions on 10/17/13, 10/31/13, 11/7/13, 11/14/13, 11/21/13,11/26/13, and 12/26/13. There were no progress notes completed for these counseling sessions.
Client #9 was admitted to treatment on 10/11/13. Per the record of services, the client attended individual counseling sessions on 11/25/13 and 12/20/13. There were no progress notes completed for these counseling sessions. Additionally, the November 2013 record of service for client #9 did not include the individual counseling sessions conducted on 11/18/13 and 11/29/13.
Client #10 was admitted to treatment on 10/29/13. Per the record of services, the client attended an individual counseling session on 12/10/13. There was no progress note completed for this counseling session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed 709.93.
On September 5, 2014, changes were made to the facility's documentation submission, review and filing protocols.
To ensure congruence in record of service and clinical documentation, Clinicians will now be responsible for completing and filing clinical documentation within 24 hours of rendered service.
Clinical Supervisor, Program Director and Quality Assurance Team will conduct weekly random chart audits to ensure that all documented treatment services were rendered, recorded and filed appropriately. |