INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.11(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 personnel records, the facility failed to ensure that each employee had a written, annual individual training plan, with input from the employee and supervisor, documented in one of four personnel records reviewed.Employee #4 was hired as a counselor on March 21, 2022. There was no documentation in the record that an individual training plan was completed as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director shall meet face-to-face with Counselor #4 to discuss needed training for 2022/2023, along with completing Individual Training Plan that is required annually. This POC shall be addressed and completed by 12/10/2022.
At this time until a Supervisor is employed, the Program Director shall follow up and meet with all Counseling staff assuring Individual Training Plans are completed and placed in personnel files. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors and facility directors during the facility's July 1, 2021 through June 30, 2022 training year in one of one applicable personnel record reviewed.Employee #1, hired as the project/facility director on June 21, 2021, only had 4.5 documented hours of annual training during the reviewed training year.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director and facility directors will complete 12 clock hours of annual training for the next training year. The training completion will be documented in the applicable personnel record. The President of the Board of Directors will be responsible for ensuring the completion of this task and requirement. Quarterly employee file review will be conducted by the President of the Board of Directors. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher in two of two applicable personnel records reviewed. Employee #2 was hired as a counselor on July 25, 2022. There was no documentation that the fire extinguisher training was provided by the facility as of the date of the inspection.Employee #4 was hired as a counselor on March 21, 2022. There was no documentation that the fire extinguisher training was provided by the facility as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will instruct all staff and new hires in the use of the fire extinguisher, and document the training. Training will be provided within 7 days of an employee's start date, and then annually.
To ensure this deficiency does not recur, the facility director will be responsible for providing this service to all new employees and planning the annual fire extinguisher training. Additionally, the HR person will be required to inform the facility director of all new hires.
Note: As of today 12/19/2022, Employee #2 and #4 have completed their fire extinguisher training. The completion of their training have been documented and uploaded into their files. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel were trained to perform assigned tasks during emergencies in two of two applicable personnel records reviewed.Employee #2 was hired as a counselor on July 25, 2022. There was no documentation that the emergency preparedness training was provided by the facility as of the date of the inspection.Employee #4 was hired as a counselor on March 21, 2022. There was no documentation that the emergency preparedness training was provided by the facility as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will instruct all staff and new hires in fire safety, conduct fire drills monthly, and ensure staff are trained to perform assigned tasks during emergencies. Trainings, and individual assigned tasks will be documented.
To ensure this deficiency does not recur, the facility director or office manager will be responsible for providing this service to all employees and planning the monthly fire drills.
Note: As of today 12/19/2022, Employee #2 and #4 have been provided emergency preparedness training. The completion of their training have been documented. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project failed to ensure that the project director annually updated and signed the written manual delineating the project's policies and procedures. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall prepare and update the written manual delineating project policies and procedures annually.
The ensure that this deficiency does not recur, the Program Director, and President of the Board of Directors will all review and sign the current policy and procedure annually prepared by the Project Director. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual and client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in five of seven client records reviewed. Per the policy and procedure manual, the facility will complete the participant's medical history, drug and alcohol history, and personal history within 30 days of admission. Additionally, per the manual, the facility will complete the participant's individual treatment plan within 30 days of admission.Client #1 was admitted on June 11, 2022 and was active at the time of inspection. The client's medical, personal, and drug and alcohol histories were due by July 11, 2022; however, the histories were not completed and signed by the clinician until August, 14, 2022.Client #2 was admitted on July 8, 2022 and was active at the time of inspection. The client's medical, personal, and drug and alcohol histories were due by August 8, 2022; however, the histories were not completed and signed by the clinician until September 6, 2022. Additionally, the client's individual treatment plan was due by August 8, 2022; however, the plan was not completed until August 17, 2022. Client #3 was admitted on July 6, 2022 and was active at the time of inspection. The client's medical, personal, and drug and alcohol histories were due by August 6, 2022; however, the histories were not completed and signed by the clinician until August 24, 2022. Additionally, the client's individual treatment plan was due by August 6, 2022, but was not completed as of the date of the inspection.Client #4 was admitted on November 21, 2021 and was discharged on June 13, 2022. The client's medical, personal, and drug and alcohol histories were due by December 21, 2021; however, the histories were not completed prior to discharge.Client #6 was admitted on April 23, 2022 and was discharged on September 15, 2022. The client's medical, personal, and drug and alcohol histories were due by May 23, 2022; however, the histories were not completed and signed by the clinician until August 11, 2022. Additionally, the client's individual treatment plan was due by May 23, 2022; however, the plan was not completed until June 26, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current new Facility/Program Director has put in place a Bi-weekly Internal Audit that will be reviewed by Counseling staff, Supervisor and Director. There will be bi-weekly supervision with Counseling staff assuring all documentation is completed within a timely manner and following all Regulations of the policies. This plan of correction (POC) is in the beginning stage of the Supervisor and Director developing an Internal Crystal percentage sheet that informs Staff, Supervisor, and Director what documents are completed and non-complete. This goal is to assure all documentation are completed at 100% within the timely manner of the policy regulation. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent form was offered to the client for every consent to release information form in all seven client records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure that a copy of a client consent form will be offered to the client for every consent to release information form. The facility director will require all staff to offer clients the opportunity to obtain a copy of the consent form in writing. Clients will be required to mark "accept" or "decline". Their response will be documented and placed in their records.
To ensure this deficiency does not recur, the facility director will perform random checks of client records to verify that the client was offered a copy of their consent form. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of the client being oriented to the project's hours of operation in all seven client records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will immediately take action to ensure that clients are oriented to the project's hours of operations through verbal and written documentation during intake and admission. Clients will be required to confirm receipt of information regarding hours of operation by signing a confirmation form.
This form will be uploaded into their records.
To prevent this deficiency from recur, facility director will perform random checks of client records, and address staff that fail to complete this task.
Facility director will review all active client records to ensure this task has been done. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of the client being oriented to the project's fee schedule in all seven client records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will immediately take action to ensure that clients are oriented to the project's fee schedule through verbal and written documentation during intake and admission. Clients will be required to confirm receipt of information regarding fee schedule by signing a confirmation form.
This form will be uploaded into their records.
To prevent this deficiency from recur, facility director will perform random checks of client records, and address staff that fail to complete this task.
Facility director will review all active client records to ensure this task has been done. |
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 client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in five of six applicable client records reviewed. Client #1 was admitted on June 11, 2022 and active at the time of inspection. The comprehensive treatment plan was signed by the counselor on June 28, 2022, but the plan was not signed by the client and there was no additional documentation in the record that indicated the plan was developed with the client.Client #2 was admitted on July 8, 2022 and active at the time of inspection. The comprehensive treatment plan was signed by the counselor on August 17, 2022, but the plan was not signed by the client and there was no additional documentation in the record that indicated the plan was developed with the client.Client #4 was admitted on November 21, 2021 and was discharged on June 13, 2022. The comprehensive treatment plan was signed by the counselor on December 13, 2021, but the plan was not signed by the client and there was no additional documentation in the record that indicated the plan was developed with the client.Client #5 was admitted on February 2, 2022 and was discharged on July 11, 2022. The comprehensive treatment plan was signed by the counselor on March 3, 2022, but the plan was not signed by the client and there was no additional documentation in the record that indicated the plan was developed with the client.Client #6 was admitted on April 23, 2022 and was discharged on September 15, 2022. The comprehensive treatment plan was signed by the counselor on June 26, 2022, but the plan was not signed by the client and there was no additional documentation in the record that indicated the plan was developed with the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, the facility director will make mandatory that all counselor must have the client sign the comprehensive treatment plan or provide a progress note stating the plan was completed with the client. The facility director will communicate this very important requirement with all counselor, and will review all record of active clients to confirm whether or not this task was completed. Additional, the facility director will perform random or weekly checks of client records to ensure counselors are meeting this requirement. |
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, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in four of four applicable client records reviewed.Client #4 was admitted on November 21, 2021 and was discharged on June 13, 2022.Client #5 was admitted on February 2, 2022 and was discharged on July 11, 2022.Client #6 was admitted on April 23, 2022 and was discharged on September 15, 2022.Client #7 was admitted on May 19, 2021 and was discharged on September 13, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction for clients #4,5,6, and 7.
The Director and Supervisor of GPASS will proceed with a biweekly internal audit to assure all required documentations are correct and complete.
Counselors will be responsible for completing all required documentation for each client assigned. All follow up for each client will be completed after every discharge.
The Supervisor will be responsible for follow up, auditing charts biweekly. |