INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Guidance For Growing, LLC, 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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709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
The facility failed to include a reference to the utilization of volunteers in their current personnel management policies and procedures. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The executive director will place documentation in the personnel management policy and procedure manual that will reflect the untilization of volunteers. Specifically, the manual will document that volunteers will not be utilized at this facility, which will be completed immediately and place under a tab labeled "VOLUNTEERS". |
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
The facility failed to include a reference to the staff rules of conduct in their current personnel management policies and procedures.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The executive director will place documentation in the personnel management policy and procedure manual that will reference staff rules of conduct.
Any mis-conduct will be addressed with staff member by the executive director. outcome of the meeting will be place in the staff's employee file.
The documentation will reflect expected behavior of staff. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
The facility failed to develop, and include with the current policy, specific procedures on how the facility would document the unusual incident.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The executive director will place documentation in the personnel management policy and procedure manual that will cite specifically how staff will document an unusual incident. This will include the development of a unusual incident form that will be filled out in the event of an unusual incident. The staff present for the unusual incident will be responsible for completion of the form within a 24 hour period. The form will be reviewed by the excutive director. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
The facility failed to develop, and include with the current policy, the specific procedures for the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The executive director will place documentation in the personnel management policy and procedure manual that will cite review of the unsual incident form.
The excutive director will consult with peers on solutions for the unusual incident and how to avoid future incidents. Results of peer review will be stored in the policy manual.
Review of the form will be performed within 48 hours by the executive director. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to develop, and include with the current policy, the specific procedures for the implementation of a timely and appropriate corrective action plan if indicated.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The executive director develop an unusual incident form, which will be in the policy manual. The staff member present during the unusual incident will be responsible for completing the form within 24 hours of the incident. Completed forms will be kept in the policy manual under an unusual incident tap. This procedure will be developed with in a 48 hour time period from the review of the unusual incident. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to develop, and include with the current policy, the specific procedures for the how the facility would monitor the corrective action plan.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The executive director will place documentation in the policy and procedure manual that will reference monitoring of a corrective action plan. Monitoring will include follow up by the executive director with staff individually one week of implementation. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
The facility failed to develop, and include with the current policy, the specific procedures for what reporting mechanism(s) the facility would utilize to ensure compliance with state and federal confidentiality laws.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The executive director will place documentation in the policy and procedure manual that will reference the agency complies with state and federal confidentiality laws. The executive director will cite how the agency utilizes release restrictions when reporting to outside parties. This will include observing the physical releases and only releasing items designated on said release. |