INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Child Guidance Resource Centers 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(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on an interview with the Administrative Director and Project Director, the facility failed to document an overall plan for addressing assessment of staff training needs and an annual evaluation of the overall training plan.
The findings include:
On March 7, 2014, the Licensing Specialist asked to see the facility's overall plan for addressing assessment of staff training needs and annual evaluation of the overall training plan. An overall plan for addressing assessment of staff training needs and an annual evaluation of the overall training plan was not presented for review.
The findings were confirmed during an interview with the Administrative Director and the Project Director on March 7, 2014 at approximately 10:30 A.M.
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Plan of Correction
The Facility Director/Clinical Supervisor and Administrative Director in collaboration with the agency Training Director will generate a departmental annual training plan evaluation document and assessment of training needs tool by 4/30/14. The annual training plan evaluation document and assessment of training needs tool will be completed annually. The Facility Director/Clinical Suprvisor and Administrative Director will be responsible for ongoing and annual monitoring of the completion of these documents. |
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 document an individual training plan annually for each employee in two of seven personnel records reviewed.
The findings include:
On March 7, 2014, seven personnel records requiring documentation of an individual training plan were reviewed. The facility failed to document an individual training plan in two of seven personnel records reviewed, specifically, personnel records # 6 and 7.
Employee # 6 is a front desk employee and was hired May 24, 2010. The individual training plan for employee # 6 was due January 31, 2014. However, personnel record # 6 did not include documentation of an individual training plan as of March 7, 2014.
Employee # 7 is a front desk employee and was hired July 7, 2013. The individual training plan for employee # 7 was due January 31, 2014. However, personnel record # 7 did not include documentation of an individual training plan as of March 7, 2014.
The findings were confirmed during an interview with the Administrative Director and Project Director at approximately 10:30 A.M.
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Plan of Correction
Employee #6 and Employee #7 will have an individual training plan completed by 4/18/14.
The Administrative Director will be responsible for the ongoing and annual monitoring of employee #6 and employee #7 training plans. The Administrative Director will be responsible for the ongoing and annual monitoring for individual training plans of all employees and make sure that individual training plans are documented annually on time of all employees. |
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 a personnel record, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of one personnel record reviewed.
The findings include:
On March 7, 2014, one personnel record was reviewed to verify that employees had HIV/AIDS and STD/TB training. The facility failed to ensure that persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training in one of one personnel record reviewed, specifically, personnel record # 6.
The findings include:
Employee # 6 is a front desk employee and was hired May 24, 2010. Employee # 6 was due to complete a minimum of 6 hours of HIV/AIDS training and at least 4 hours STD/TB training by May 24, 2012. However, personnel record # 6 did not include documentation of HIV/AIDS and STD/TB training as of March 7, 2014.
The findings were confirmed during an interview with the Administrative Director and Project Director at approximately 10:30 A.M.
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Plan of Correction
Employee #6 will schedule and complete a minimum of 6 hours HIV/Aids training and at least 4 hours STD/TB training by 5/31/2014. Administrative Director in collaboration with agency Training Coordinator will be responsible to ensure that 6 hours HIV/Aids training and at least 4 hours STD/TB is scheduled and completed for employee #6.
In addition, Administrative Director and Training Coordinator will be responsible for and make sure that all new and existing employees complete HIV/AIDS and STD/TB training on time. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of fire drill records, the facility failed to conduct fire drills during normal staffing conditions in five of eleven months reviewed. Also, the facility failed to have documentation for the time, amount of time it took for evacuation, the exit route used, the number of person in the facility at the time of the drill, whether the fire alarm or smoke detector was operative, and/or preparing alternate exit routes in eleven of eleven months reviewed. In addition, the facility to have documentation that they set off a fire alarm or smoke detector during each fire drill in eight of eleven months reviewed
The findings include:
Fire drill records were reviewed on March 5, 2014. The records were reviewed from the period covering April 2013 to February 2014. The facility did not conduct fire drills during normal staffing conditions in five of eleven months reviewed, specifically, June 2013; July 2013; September 2013; December 2013; and January 2014. Also, the facility did not have documentation for the time, amount of time it took for evacuation, the exit route used, the number of person in the facility at the time of the drill, whether the fire alarm or smoke detector was operative, and/or preparing alternate exit routes in eleven of eleven months reviewed, specifically, April 2013; May 2013; June 2013; July 2013; August 2013; September 2013; October 2013; November 2013; December 2013; January 2014; and February 2014. In addition, the facility did not have documentation that they set off a fire alarm or smoke detector during each fire drill in eight of eleven months reviewed, specifically, April 2013; May 2013; June 2013; July 2013; August 2013; October 2013; January 26, 2014; and February 2014.
The findings were confirmed during an interview with the project director and maintenance staff on March 7, 2014 at approximately 10:30 A.M.
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Plan of Correction
Effective March, 2014,Fire drills will be conducted for all 12 months of the year during normal staffing hours and conditions.Fire drill form has been revised to include that fire alarm or smoke detector has been set off, amount of time for evacuation, exit route used, time of drill, number of staff, clients/ visitors evacuated, the operational status of the fire alarm and smoke detector system and comment section now specifies "Describe any unusual circustances or problems." The Division Director of Performance Improvement/Chair person of Environment of Care Committee will conduct fire drills and will be responsible for ongoing monitoring that fired drills are conducted every month and documentation is completed and in full compliance with regulation. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug or alcohol history that included the substances most frequently abused and the length and patterns of use in one of two client records reviewed.
The findings include:
On March 7, 2014, two client records requiring documentation of a drug or alcohol history were reviewed. The facility did not document a drug or alcohol history that included the substances most frequently abuse and the length and pattern of use in one of two client records reviewed, specifically, client record # 1.
Client # 1 was admitted November 11, 2013. The drug or alcohol history was completed October 27, 2013 but did not include the substances most frequently abused and the length and patterns of use as of March 7, 2014.
The findings were confirmed during an interview with the facility director on March 7, 2014 at approximately 11:30 A.M.
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Plan of Correction
The drug and alcohol history for client #1 has been amended on 3/31/14 to include the client's substances most frequently abused and length of patterns of use. In addition, Facility Director/Clinical Supervisor has ensured that this documentation has been amended in client #1 record.
The Facility Director/Clinical Supervisor will also provide training to counselor to ensure that documentation of drug or alcohol history includes substances most frequently abused and the length of patterns of use. The training will be conducted on or before 4/18/14. The Facility Director/Clinical Supervisor will ensure compliance by monitoring during weekly supervision with counselor and monthly chart reviews. |
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, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in two of two client records reviewed.
The findings include:
On March 7, 2014, two client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in two of two records reviewed, specifically, client records # 1 and 2.
Client # 1 was admitted November 11, 2013. The individual treatment and rehabilitation plan was completed November 11, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of March 7, 2014.
Client # 2 was admitted June 14, 2013. The individual treatment and rehabilitation plan was completed July 8, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of March 7, 2014.
The findings were confirmed during an interview with the facility director on March 7, 2014 at approximately 11:30 A.M.
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Plan of Correction
The Facility Director/Clinical Supervisor will provide training to counselor to ensure that proposed type of support services is included in the individual treatment and rehabilitation plan for all clients by 4/18/14. The Facility Director/Clinical Supervisor will ensure compliance by monitoring during weekly supervision with counselor and during monthly client chart reviews. |