INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 3, 2015 and a follow-up inspection on June 9, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation during the physical plant inspection, the residential facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
A physical plant inspection was conducted on June 3, 2015. The facility failed to keep the grounds of the facility in clean, safe, and in good repair as a light in the second floor bathroom was damaged and in need of repair, an air condition in a counselor's office had the wires crossing in front of the door requiring the air conditioner to be unplugged before the door could be opened, and there was a metal chain hanging from the second floor ceiling that posed a hazard.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The light in the 2nd floor bathroom was repaired and affixed properly to the ceiling the same day 6/3/15 and a photo was sent to the state the next day. The air conditioner in room 7 had a new air conditioner appropriate extension cord added and the cord securely fixed to the door frame so that there is no wire blocking the door the repair was done on 6/4/15. The skylight chain that was hanging low near the front steps of the second floor was raised on 6/3/15.
A walk through inspection will be done monthly and a check list will be designed to look for any hazards in the facility.
Housekeeping will be responsible for keeping the facility clean. Our building maintenance person, as well as the Facility Director will oversee the check list and do the walk through the building. Housekeeping will be responsible for keeping the facility clean. The maintenance person will be responsible for fixing any hazard issues within the facility. The deficiencies noted have been corrected. Housekeeping new rules will be corrected by June 26, 2015.
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705.27 (1) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on the results of staff interviews, the facility failed to ensure that it was free of rodent and insect infestation at all times.
The findings include:
Staff who were interviewed on June 3, 2015 verified that there were observations of mice and roaches in the facility. The last invoice for Peerless Pest Control was reviewed and the date listed was December 24, 2014. Services rendered that were listed on the invoiced included mice and roaches.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The issue of mice and roaches in the facility will be corrected by having Peerless Pest Control at 5246 N. 5th Street Philadelphia, PA 19120, (215) 324-4719 will be out monthly. The first extermination was done on Friday 6/12/15 at GPASS. The first date of the Peerless Pest Control extermination was observed by the Facility Director. The exterminating contract is set up for the first Monday of each month after the 6/12/15 was performed. The Executive Director will be responsible to oversee that the monthly contract is valid. This deficiency has been corrected.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's Fire Drill Log, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
The facility's Fire Drill Log for the months of January to June of 2015 was reviewed on June 3, 2015. The facility failed to document that a fire drill was conducted for January and May of 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A fire drill will be conducted monthly on different days, times, and exits from GPASS. A fire captain and assistant fire captain will be appointed by the facility director. The fire log will be the responsibility of the fire captain and assistant. The facility director will be responsible to check on the fire captain's log for compliance.
The fire captain will also check for blockage in the halls, as well as any other fire hazard monthly and a Fire and other hazard form will be made for GPASS. This will be corrected by June 26, 2015
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to comply with 4 Pa. Code 255.5 and 42 CFR Part 2 (relating to projects and coordinating bodies: disclosure of client-oriented information).
The findings include:
Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Four client records were reviewed on June 9, 2015. All four records contained a form labeled Rights and Responsibilities which the clients were required to sign. The Rights and Responsibilities form contained an exception clause to obtaining a written consent that stated: "when your records are required by your insurance company in order to gain continued authorization for service at SAFE Outpatient Counseling; when your records are requested by your insurance company in order for SAFE Outpatient Counseling to receive payment for services rendered; and in an emergency situation when you are unable to give informed consent, to the extent that the information is necessary and appropriate to the event".
That form indicated that the facility ' s policy allowed for the release of information that exceeded 4 Pa. Code 255.5 and 42 CFR Part 2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
GPASS Rights and Responsibility Form will be redone to include the language that is in the Pa. Code 255.5 and 42 CFR part 2. and the incorrect information deleted from the form. The new form will be prepared by June 19th by the facility director and initiated into patient charts by June 22nd,2015.A copy will be submitted to the State if requested. |