INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 12 and 13, 2008 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 and a plan of correction is due on June 9, 2008.
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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 administrative documents on May 12, 2008, the facility failed to document that the project director is responsible for the overall management of the project and staff. The organizational chart does not indicate that the project director reports directly to the Board and is responsible for the overall management of the project.
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Plan of Correction
The organizational chart will be reviewed and/or updated on a quarterly basis. The Project Director has been selected to be responsible for the overall management of the program and the staff. The policy manual will be revised to reflect that the governing body selects the Project Director and the Project Director reports directly to the board. |
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 on May 12, 2008, the facility failed to document that one of five counselors met the qualifications for this position, #7. Employee #7 did not have the educational requirements for this position.
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Plan of Correction
The Program Director will ensure that all potential staff has the required education, qualifications and/or credentials before being hired. The applicant will submit a transcript of his completed education credits. This will be implemented immediately
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records and an interview with project director on May 12, 2008, the facility failed to document direct observation for employee #8.
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Plan of Correction
The Program Director will perform direct observation in the sessions of the counselors assistants. The Program Director will inform clients of the purpose the direct observations and client's consent for the Program Director to directly observe the sessions. The Program Director will notes the actions and performance of the counselors assistants to be documented and discussed in supervision of the counselors assistants. Program Director will document the sessions as well as the counselors assistants and the Program Director notes will placed in the clients chart along with the counselors assistants note regarding the session. The Program Director will create and utilize a supervision record sheet and chart review form to document supervision for counselor's assistants. The Program Director will provide documentation of supervision for counselor's assistants. The documentation will be placed in the counselor's assistant's personnel file. The Program Director will be responsible for monitoring the counselor's assistants in weekly supervision ensure that this takes place and to ensure that this deficiency does not recur. The Program Director will be responsible for ensuring the corrective action is implemented. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of training records on May 12, 2008, the facility failed to document an assessment of staff training needs in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
The Program Director has created a new assessment format. The assessment will be reviewed and updated a monthly basis. The Program Director will ensure completion of the training assessment at the end of each fiscal year.The Program Director will be responsible for ensuring the corrective actions is implement. |
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 training records on May 12, 2008, the facility failed to document potential resources on individual training plans in seven of seven records reviewed, #1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
The Program Director is responsible for documenting potential resources in individual training plans. The documenting of potential resources in individual training plans will be done every 30 days or as needed. The Program Director will responsible for monitoring the individual training plans for compliance. |
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 training records on May 12, 2008, the facility failed to document HIV/AIDS training in two of four records reviewed, #5 and 6. Additionally, the facility failed to document TB/STD training in one of four records reviewed, #5.
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Plan of Correction
The Program Director will identify upcoming HIV/AIDS and STD/TB training and implement corrective action(s). That staff will be registered to attend the next upcoming training. I The program Director will be responsible for documenting that all staff receives the mandatory training within the required timeframes. A documented training record will be established for each staff. The record will be reviewed in supervision to ensure compliance and placed in the staff personnel file. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on the physical plant inspection on May 13, 2008, the facility failed to store all trash in covered containers. There were three trash containers outside the building which did not have covers.
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Plan of Correction
The trash can was removed and replaced by a new trash can that is constructed that the lid is part of the trash can and cannot be removed from the can. The trash can lid covers the trash can at all times. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on the physical plant inspection on May 13, 2008, the facility failed to have a light for the second floor rear exit.
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Plan of Correction
The light at the exit was properly installed on 05/20/08. The Project Director will perform a physical and environmental inspection of the facility monthly. A record of the result of the inspection will be kept. A record of repairs and corrections will be logged. The date of the inspection and the date of the repairs or correction will be documented. |
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 on May 12, 2008, the facility failed to document that staff were instructed in the use of the fire extinguisher within the required time frame in four of eight personnel records reviewed, #3, 5, 6 and 7. Fire extinguisher training was documented late. Additionally, there was no documentation that any instruction was received in one of eight records, #8.
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Plan of Correction
The Program Director will cover fire safety training including the proper use of a fire extinguisher is initial trainings and new staff orientations. The training will take place within the required timeframe of seven days for new hires. The Program Director will provide specialized ongoing training regarding fire safety including the use of fire extinguisher during the year. The training will document in the required time frame. The appropriate documentation will be placed in for the staff's personnel file. |
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 on May 12, 2008, the facility failed to document training for assigned tasks during emergencies in four of eight personnel records reviewed, #2, 5, 6 and 7.
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Plan of Correction
The emergency protocol is included in the orientation. The emergency protocol training will be conducted within the required timeframe of seven days for new hires. This was placed since the last audit; therefore, some of the older staff did not have the same forms. Since this audit, the Project Director went over the emergency protocol and also obtained signature stating that this was reviewed with staff |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of of the fire drill record on May 13, 2008, the facility failed to document that a fire alarm or smoke detector was set off during each fire drill since the October 2007 inspection.
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Plan of Correction
The Facility Director has changed documentation that now includes a section to address if the fire alarm or smoke detector was set off. The Facility Director will maintain the record. This will take place starting June 2008. |
709.22(e) 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:
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Observations
Based on a review of administrative documents on May 12, 2008, the facility failed to document that the 2006/2007 annual report was made available to the public within the required time frame. The availability of the annual report was not advertised until 3/27/08.
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Plan of Correction
GPASS fiscal year ranges from July 1-June 30. The Project Director will make sure that the annual report is completed by June 30 of that annual year. The Project Director will make sure to begin the process during the month of May. Therefore, the annual report will be available to the public six months after the end of the fiscal which would 12/31/08, the Project Director will make sure the annual report is make available to the public by December 31 of each year. |
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 administrative documents on May 12, 2008, the facility failed to document a statement disclosing the names of officers and directors of the board within the 2006/2007 annual report.
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Plan of Correction
The Project Director review and update the names of officers and directors of the board on a monthly basis. The Project Director will include all names of the officers and directors of the board for the upcoming 2007-08 annual report and all subsequent reports thereafter. |
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 on May 12, 2008, the facility failed to document available resources for 2008 project goals and objectives.
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Plan of Correction
The Project Director will be responsible for this objective. The Project Director will identify appropriate resources and incorporates those resources in staff meetings and supervision. The Project Director will document these goals and objectives and also present it to the Board of Directors and officers (which will be reflected in the minutes). This will be implement immediately. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documents on May 12, 2008, the facility failed to document that the 2006/2007 audit was completed by December 31, 2007. The audit was not completed until 1/17/08.
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Plan of Correction
The Project Director will make sure to have the audit scheduled before the end of each fiscal year (June 30). The Project Director will ensure the audit is completed within six months of the end of the fiscal year or at the latest December 31 |
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 the physical plant inspection on May 13, 2008, the facility failed to secure clients records within locked storage containers. The client records were stored in unlocked filing cabinets in an office used for the billing clerk. At the time of the inspection the door to this office was unlocked and the filing cabinets did not have locks.
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Plan of Correction
The Program Director will explain the importance of securing the records in initial trainings and orientations of all staff. The Program Director will provide ongoing training regarding proper records security. The Facility Director and Program Director will ensure proper security of the records room and instituted new procedures to this end. The records will be stored in locked cabinets, The records security protocols will be discussed in staff meeting and supervision.
When there is no staff in attendance the door is always closed and locked. GPASS will make sure to just keep the door closed and lock. This will implemented immediately.
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709.28(c) 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:
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Observations
Based on a review of client records on May 13, 2008, the facility failed to obtain an informed and voluntary consent from the client in five of five records reviewed, #1, 2, 3, 4 and 5. Consent to release information forms to the funding source and probation officers included "request from" language which must be removed from the consent form since the law and regulation does not address or regulate entities wanting to request information. The Consent for Treatment form signed in five of five client records reviewed, #1, 2, 3, 4 and 5, stated that the "probation officer will be informed of homicidal/suicidal threats, behaviors, ideation and activities contrary to court stipulations". The Rights and Responsibilities form signed in five of five client records reviewed, #1, 2, 3, 4 and 5, stated that GPASS will require written consent to release records except "when your records are required by your insurance company in order to gain continued authorization for services".
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Plan of Correction
The Program Director has changed and updated all consent forms. These new forms have been in effect since 05/19/08. The Program Director will review, revise or update all consent forms as needed. The Program Director has informed staff members regarding these changes. The Program Director review charts in weekly supervision to ensure all new consent forms are being used. |
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 on May 13, 2008, the facility failed to obtain an informed and voluntary consent from the client in three of five client records reviewed, #1, 3 and 5. The specific information to be disclosed on a consent to the probation officer exceeded the limitations imposed at 4 Pa. Code 255.5 in two records, #1 and 3 . The information to be released included the urine drug screen. The specific information to be disclosed to Community Behavioral Health and to the Forensic Intensive Recovery Program exceeded 4 Pa. Code 255.5 in one record, #5. The information included the urine drug screen.
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Plan of Correction
The Program Director has changed and updated these GPASS have been using these new forms since 05/19/08.
The Program Director will review, revise or update these forms as needed. The Program Director has informed staff members regarding these changes. The Program Director review charts in weekly supervision to ensure all new forms are being used
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on May 13, 2008, the facility failed to document a complete psychosocial evaluation in five of five client records reviewed, #1, 2, 3, 4 and 5. The psychosocial evaluations in #1, 2, 4 and 5 were a repeat of historical data and did not include assets/strengths, support systems, negative factors, coping mechanisms and attitude toward treatment. There was no psychosocial evaluation documented in #3.
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Plan of Correction
The Program Director will highlight importance of biopsychosocial clinical summary during initial trainings and orientations of all staff. The Program Director will provide ongoing training regarding the biopsychosocial clinical summary. The charts and biopsychosocial clinical summary will review in weekly supervision by Program Director to ensure compliance to the policy for completing biopsychosocial clinical summaries. The biopsychosocial clinical summary has been updated. On the new forms, it identifies required information including assets/strengths, support systems, negative factors, coping mechanisms and attitude toward treatment. The Program Director will be responsible for ensuring the corrective actions is implement. This was implemented immediately. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of facility policy and client records on May 13, 2008, the facility failed to document that preliminary treatment plans were completed within the time frame prescribed in the facility's policy in three of five records reviewed, #3, 4 and 5. The prescribed time frame required preliminary treatment plans to be completed within 15 days of admission. The preliminary treatment plan was completed five days late in client record #3, 44 days late in client record #4 and 20 days late in client record #5.
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Plan of Correction
The Program Director will stress the importance of in preliminary treatment in initial trainings and orientations of all staff. The Program Director will provide ongoing trainings regarding preliminary treatment planning. The Program Director will review charts in weekly supervisions to ensure compliance to policy for preliminary treatment planning. Treatment plan protocol will be discussed in staff meeting and supervision. This will be implemented immediately. |
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 facility policy and client records on May 13, 2008, the facility failed to document individualized treatment plans in two of five client records reviewed, #1 and 2. The goals and action steps were identical in the treatment plans for these two clients. Additionally, treatment plans were not completed within 30 days of admission as prescribed by facility policy in two of five records reviewed, #2 and 4. The treatment plan was completed 37 days from admission in client record #2 and 64 days from admission in client record #4.
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Plan of Correction
The Program Director will provide training to staff on individualized training plans in initial trainings and orientations. The Program Director will provide ongoing trainings regarding individualized treatment planning. The Program Director will review charts on a weekly basis and discuss treatment plans in weekly supervsion or when needed to ensure the treatment plans are individualized for each client. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on May 13, 2008, the facility failed to document proposed types of support services in the treatment plans in three of five client records reviewed, #1, 2 and 3.
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Plan of Correction
The Program Director will stress the importance of support systems in initial trainings and orientations of all staff. The Program Director will provide ongoing trainings regarding locating and accessing proper support systems. The issue of Support systems has been added to the treatment plan (will be included in the progress/update section). The Program Director will review charts weekly to ensure support systems are addressed. The Program Director is biopsychosocial clinical summary are responsible for ensuring the corrective actions is implemented. This action will be implemented immediately. |
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 on May 13, 2008, the facility failed to document a complete treatment plan update in four of five records reviewed, #1, 2, 3 and 5.Treatment plan updates were missing in two records, #1 and 5. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan in two records, #2 and 3.
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Plan of Correction
The Program Director will emphasize the importance of proper comprehensive treatment plan up-dates in initial trainings and orientations of all staff. The Program Director will provide ongoing trainings regarding comprehensive treatment plan up-dates. The Program Director will monitor and review charts weekly for treatment Plan updates compliance. The treatment plan up-dates will be discussed in supervision on
a weekly basis to ensure that the deficiency regarding treatment plan up-dates does not recur. Treatment Plan will be discussed individual and group supervision.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records on May 13, 2008, the facility failed to document case consultations in five of five client records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
The Program Director will emphasize the importance of Case consultation in initial training and orientation of all staff. The Program Director will provide ongoing trainings. The Program Director will review charts weekly and document that review to ensure compliance. The Program Director will monitor compliance and discuss Case consultation in supervision. This action will be implemented immediately. |
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 on May 13, 2008, the facility failed to document follow-up information in two of four client records reviewed, #6 and 8.
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Plan of Correction
The Program Director will train the staff in initial trainings, new staff orientations and ongoing trainings about proper follow- up documentation. The charts will be reviewed on weekly basis by the program director to ensure that this deficiency does not recur. |