INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4 through 5, 2012 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:
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of employee #1's job description, the project's organizational chart and a conversation with the Chairman of the Board of Directors, the project failed to ensure that the staff person appointed to the position of project director would be responsible for the overall management of the project and staff. The findings include:The published definition for project director as found in 28 Pa. Code, 701.1 is as follows:Project director - The administrator of the treatment project who is responsiblefor the overall management of the project and staff and who meets the educationand experience requirements in Chapter 704.A review of employee #1's job description and the organizational chart did not indicate that employee #1 was responsible for the overall management of the project and staff. An interview with the Chairman of the Board of Directors confirmed that the person responsible for the overall management of the project and staff was not employee #1. Additionally, the person who was responsible for the overall management of the project and staff did not meet the educational requirements for the position.
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Plan of Correction
The Program Director and Executive Director reviewed Pa. Code, 701.1 and presented the findings to GPASS Board of Directors.
The Board of Directors will request an exception petition permitting the employee, based upon experience, be responsible for the overall management of the project and staff even though the employee does not meet the educational requirements for the position.
If this exception is not granted, the project will comply prescriptively. |
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 all employees hired for the position of counselor met the qualifications.The findings include:Six personnel records for the position of counselor were reviewed on September 4-5, 2012. The facility failed to ensure that one of six counselors, employee #8, met the qualifications for this position. Employee #8 did not have the educational requirements for this position. Employee #8's degree was an Associates Degree in Liberal Arts with a general option. This does not meet the requirements for the position of counselor. Additionally, the facility was unable to produce documentation for any clinical experience. The Clinical Supervisor confirmed the findings.
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Plan of Correction
Following the state's review, the Clinical Supervisor reviewed electronic files for the former Program Director and identified direct supervision notes for employee #8.
These notes reflect direct supervision for the employee's first 4 months of employment.
Employee #8 received a performance evaluation on April 6, 2012 and on June 8, 2012. The next performance evaluation is for December 7, 2012.
Documentation for direct supervision and evaluations will be forwarded to DDAP.
The employee continues to receive weekly individual and group supervision.
To ensure this deficiency does not occur again, the Program Director will review all prospective employee credentials through an approved website and will ensure that sufficient work experience has been obtained via contact with references at prior employers. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility staff first aid certification cards, the facility failed to ensure that at least one person trained in first aid skills was onsite during the project's hours of operation. The findings include: Based on a review of staff schedules and staff first aid certification cards, the facility did not have documentation for first aid training for 7 of 8 employees records reviewed. The facility's hours of operation are from 9:00AM-5:30PM. The only documented time that the facility had a staff person on duty with first aid training was from 5:30-8:00PM Monday-Friday. There was not documented coverage between the hours of 9:00AM-5:30PM Monday-Friday.The Clinical Superviror confirmed the findings.
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Plan of Correction
The Clinical Supervisor has reviewed options for in-house and off-site trainings for First Aid.
All SAFE department staff have been scheduled for First Aid training. Training dates are as follows:
November 27 in-house
December 5 in-house
December 20 off-site
The Clinical Supervisor will conduct yearly personnel record reviews to ensure that all staff are up to date with CPR and First-Aid certification.
While staff are being trained, coverage for First-Aid is being provided by the following certified employees: two clinicians working 9a-5p Monday-Friday, the Executive Director working 5p-8p Monday-Friday, and one more clinician working 12p-8p Monday-Friday. |
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 observations during the physical plant inspection, the facility failed to ensure that there were no heaters that were not permanently mounted or installed within the facility.The findings include:The physical plant inspection was conducted with the Clinical Supervisor on September 5, 2012 between 9:00-9:30 AM. The Licensing Specialists observed eight portable heaters in the basement closet.The Clinical Supervisor confirmed the findings.
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Plan of Correction
The Executive/Facility Director reviewed concerns pertaining to the storage of portable heaters in the facility.
All portable heaters were removed by maintenance staff.
The Facility Director will conduct monthly tours of the building to ensure that no portable heating or cooling devices are on premises.
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705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on observations during the physical plant inspection, the facility failed to ensure the smoke detectors on all floors were operable.The findings include:The physical plant inspection was conducted with the Clinical Supervisor on September 5, 2012 between 9:00-9:30 AM. The Licensing Specialists observed a smoke detector in the basement with a plastic covering over it. The plastic was removed at the time of inspection.The Clinical Supervisor confirmed the findings.
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Plan of Correction
The Clinical Supervisor removed the plastic covering from the smoke detector at the time of inspection.
The Facility Director will conduct montly tours of the facility prior to scheduled fire drills to ensure that all fire warning systems are uncovered and fucntioning properly. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill logs, the facility failed to maintain a written fire drill record that included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm and/or smoke detector was operative.The findings include:The fire drill log was reviewed on September 4, 2012. The facility failed to document on the log whether or not the fire alarm and/or smoke detectors were operable. The log was updated at the time of inspection to include this information.The Clinical Supervisor confirmed the findings.
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Plan of Correction
The Clinical Supervisor completed a review of Fire Drill Log templates and made appropriate revisions to include a functional check of fire alarms and smoke detectors.
The Clinical Supervisor and Facility Director will conduct monthly random fire drills that will include a check of fire warning systems for proper functioning. |
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 the 2011 annual report, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders, as required by regulation.The findings include:The 2011annual report was reviewed on September 4, 2012. The facility is publicly funded and required by regulation to make available to the public an annual report which includes a statement disclosing the names of officers, directors and principal shareholders. The facility made the 2011 annual report available to the public via their website. The 2011 annual report did not include a statement disclosing the names of the current officers, directors and principal shareholders. The board list provided with the annual report was from July 2008. The Clinical Supervisor confirmed the findings.
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Plan of Correction
The Clinical Supervisor addressed the annual report deficiency with the Executive Director and the SAFE Board of Directors.
The Executive Director and SAFE Board of Directors agreed to publish an electronic copy of the annual report on the GPASS website.
The Executive Director will ensure this deficiency does not reoccur by presenting the annual report to the GPASS IT professional following the board's review of each year's annual report.
This change will be effective following the completion of the 2012 GPASS annual report.
THe 2011-2012 Annual Report will be made available via the agency's website upon its completion, at this time, a hard copy of the agency's annual report will be forwarded to DDAP. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documents, the facility failed to develop goals and objectives which included time frames and available resources.The findings were:A review of the facility's policy and procedures manual on September 4, 2012 indicated that the annual goals and objectives were missing time frames and resources for the year July 1, 2011 to June 30, 2012. The Clinical Supervisor confirmed findings.
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Plan of Correction
The Program/Clinical Director and Executive Director reviewed the current format for goals and objectives and have made changes to the basic format to include notation of timeframe and necessary resources.
The Program/Clinical Director has made ammendments to the July 1, 2011 - June 30, 2012 goals and objectives to establish compliance with state regulations.
To ensure this deficiency does not occur again, the Program/Clinical Director and Executive Director will complete quarterly review of project goals and achievements which will be noted on the new template to include statements of: goals, objectives, time frames and available resources. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on a review of administrative documents, the facility failed to obtain written letters of agreement or understanding with primary referral sources.The findings were:During a review of the facility's policy and procedure manual on September 4, 2012, it was noted the only letter of agreement with primary referral sources on file was a job referral agreement with Soar Corp. The Clinical Supervisor confirmed the findings.
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Plan of Correction
The Program/Clinical Director and Executive Director reviewed administrative documents and found two active referral agreements: one with an outpatient D&A facility and another with a mental health crisis unit.
One direct referral agreement with a hospital system was found misfiled and has been filed with the other active referral agreements.
The Program/Clinical Director has obtained a direct referral agreement with an LGBTIQ counseling center and is currently finalizing a referral agreement with another behavioral healthcare provider.
To ensure adequate referral agreements are in place, the Program/Clinical Director and the Executive Director will conduct annual reviews of active referral agreements to ensure they are active and appropriate for the population served at GPASS. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations as required by agency policy.The findings include:Five personnel records were reviewed on September 5, 2012. Per agency policy, performance evaluations are conducted within 90 days of hire and annually thereafter. The annual performance evaluation was not documented in one out of five records, employee #1. The last documented evaluation was completed on 12/9/09 for employee #1.The Clinical Supervisor confirmed the findings.
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Plan of Correction
The Program/Clinical Director, Executive Director and Chariman of the Board of Directors reviewed state regulations on performance evaluations.
The Executive Director, employee #1, will receive a yearly evaluation by a member of the Board of Directors.
To resolve the current deficiency, a yearly evaluation for employee #1 was completed on September 17, 2012.
To ensure this deficiency does not occur again, a quarterly review of the Executive Director, employee #1, personnel record will be conducted to ensure that amble time is provided to the Board of Directors for a completion of performance evaluation. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
During the physical plant inspection it was noted that the facility failed to secure some client records within locked storage.The findings include:A box of records for clients who were in treatment for one day were stored in a cardboard box in an unsecured closet in the basement.The Clinical Supervisor confirmed the findings.
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Plan of Correction
The Program/Clinical Director and Executive Director reviewed necessary record storage protocols.
Four locking metal filing cabinets were purchased and all unsecure records were moved to these filing cabinets. The filing cabinets are stored behind locking doors within the facility.
To ensure this deficiency does not occur again, the Program/Clinical Director has reviewed client record storage protocol with all staff. The Program/Clinical Director will be responsible to monitor the storage of all client records. |
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 on a review of client records, the facility failed to document an informed and voluntary consent.The findings include:Eight client records were reviewed on September 5, 2012. In one of eight, it was noted that five consents to release information did not have who the information was being disclosed to and for what purpose. Three consents were signed and dated and included the areas of information to be released. The remaining two consents in this record were signed and dated only. The Clinical Supervisor confirmed the findings.
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Plan of Correction
A review of confidentiality policy and procedure was conducted by the Clinical Supervisor prior to the 10/31/12 scheduled Team Meeting.
The Clinical Supervior held a training during the 10/31/12 clinical team meeting that addressed confidentiality and the appropriate steps to obtain consent for release of information. Samples of appropriate release of information forms were distributed.
Prior to the 10/31/12 clinical team meeting, the Clinical Supervisor cretaed a Compliance Review Committee, established 10/2/12, that meets weekly to review all clinical chartwork for compliance. The results of the committee's findings are presented to the Clinical Supervisor on a weekly basis.
The Clinical Supervisor and Lead Counselor will be responsible for ensuring that all rleases of information are accurately filled out and in compliance with state and federal regulations. Weekly team meeting and compliance review committee meetings will be held. Deficiencies will result in disciplinary action. |
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 client records and a review of the facilities policy and procedures manual, the facility failed to document a complete client record according to policy.The findings include:The facilities policy states:The facility will follow-up with discharged clients by letter to their last known address or by phone within 30 days of discharge.Four discharged client records were reviewed on September 4-5, 2012 for follow-up documentation.The facility failed to document follow-up per policy in one of four client records reviewed, specifically client record #8.Client # 8 was admitted to the program on 3/28/12 and discharged on 6/22/12. A follow-up was due on 7/22/12. The follow-up was completed on 8/20/12. The Clinical Supervisor confirmed the findings.
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Plan of Correction
The Program Director has reviewed the case record for client #8. This client was discharged from treatment on 6/22/12 and readmitted to treatment on 6/27/12 thus negating the need for follow-up contact on 7/22/12.
Client #8 was then discharged again on 7/24/12 with follow-up contact completed on 8/20/12. Documentation verifying client #8's status will be forwarded to DDAP.
To ensure this deficiency does not recur, Program Director will conduct weekly review of the project's discharge list to ensure accuracy in documenting discharges and follow-up contacts. |