INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21 & 22, 2021 by the staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the finding of the on site inspection, Community Guidance Center 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of the project's policy and procedures manual, the project failed to develop a written policy on the recruitment and hiring staff persons who are appropriate to the population to be served.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Community Guidance Center has update the policy for the recruitment and hiring of individuals appropriate to the population that is being served. It is currently being reviewed by the board of directors. Policy was developed with the Facility Director, Drug and Alcohol Supervisor, Chief Operations Office, and Chief Human Resources Officer. |
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 the personnel records, the facility failed to document an individual training plan for employee #1.
Employee #1 was hired on February 1, 2021 and was still employed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual training plans will be completed along with performance evaluations and will occur on each fiscal year. Facility Director and Chief Human Resources Officer will be in charge of assuring plans are completed and evaluations conducted yearly. |
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 review of the facility's fire drill logs from August 2019 to July 2021, the facility failed to conduct unannounced fire drills during the months of November and December 2020 and January and February of 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills will be conducted by the Facility Director and the Clinical Supervisor. Completed fire drills will be scanned in and then sent to the Chief Operations Officer and placed in a binder for review and records retention. Fire Drills will occur on a monthly basis. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records on July 21 & 22, 2021, the facility failed to document a completed informed and voluntary consent to release information form prior to the disclosure of information in three out of the seven client records reviewed.
Client #5 was admitted on February 25, 2021 and discharged on May 12, 2021. A consent to release information was signed by a witness dated February 23, 2021 for the funding source. The facility confirmed that the funding source was billed for services.
Client #7 was admitted on February 9, 2021 and discharged on April 23, 2021. There was a consent to release information for the funding source sign and dated by a witness on February 28, 2021. The facility confirmed that the funding source was billed for services.
Client #7 was admitted on February 9, 2021 and discharged on April 23, 2021. There was a consent to release information for a governmental agency sign and dated by a witness on February 28, 2021. The facility made contact with the governmental agency on February 9, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Community Guidance Center will send out releases of information to the consumer prior to the intake should it be via telehealth to assure that confidentiality is maintained. If the intake is done via in person, consumer will complete releases of information during the intake process. It will be noted in the chart when the releases are sent out should the intake occur via telehealth. The Community Guidance Center will also evaluate the viability of using an electronic signature system to assure that documents are signed in a timely manner. |
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 the client records on July 21 & 22, 2021, the facility failed to document that the client was offered a copy of the informed and voluntary consent to release information.
Client #1 was admitted on February 1, 2021 and was an active client at the time of the inspection. There were seven informed and voluntary consents to release information in the client record that did not have proper documentation that the client was offered a copy of the consent. The consents were for funding source, governmental agencies, social service agencies, medical providers and a family member.
Client #4 was admitted on March 8, 2021 and was and active client at the time of the inspection. There were six informed and voluntary consents to release information in the client record that did not have proper documentation that the client was offered a copy of the consent. These consents were for the funding source, governmental agencies, social service agencies and a family member.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Community Guidance Center will work to identify the releases that are not documented correctly and offer a copy to the consumer. Consumer will initial the release either accepting a copy or rejecting a copy. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of the client records during the inspection on July 21 & 22, 2021, the facility failed to obtain a written signed consent to treat from the client.
Seven out of seven client records reviewed did not have documentation that the client signed a consent to treat form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Community Guidance Center will send out a consent to services with a self-addressed envelope to be returned after it is signed should the intake occur via telehealth. It will be noted in the Electronic Health Record when it was sent out in the mail. |
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, the facility failed to document treatment plan updates within the regulatory timeframe in two out of six client records reviewed.
Client #5 was admitted on February 25, 2021 and discharged on May 12, 2021. A treatment plan update was completed on March 1, 2021 and the next update was due no later than April 30, 2021; however, the updated treatment plan was completed on May 12, 2021.
Client # 6 was admitted on February 2, 2021 and was discharged on June 25, 2021. A treatment plan was completed on February 18, 2021 and the next update was due no later than April 10, 2021; however, the updated treatment plan was completed on April 14, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Community Guidance Center will review with staff the due dates of treatment plan updates. Treatment plans will be monitored via internal chart auditing performed by D&A Supervisor or other designated staff to ensure documentation is performed in a timely manner. This will be reviewed with staff at scheduled supervision sessions to maintain adherence to regulations and best care for consumers. |
709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of the projects policy and procedures manual, the project failed to develop a written policy on outreach services to include identifying persons in need of the project services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Community Guidance Center has developed a policy to identify the priority populations. It is currently being reviewed by the board of directors. |
709.94(f)(2) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on a review of the projects policy and procedures manual, the project failed to develop a written policy on outreach services to include alerting persons and their families to the availability of the project services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Community Guidance Center is in the process of developing a policy for the outreach services and alerting individuals and their families of the services that are provided by the center. |
709.94(f)(3) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on a review of the projects policy and procedures manual, the project failed to develop a written policy on outreach services to include encouraging person to utilize the service delivery system.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Community Guidance Center is currently developing a policy for the outreach services to encourage persons to utilize the service delivery system. |