INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings 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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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure to the clients of the criteria for admission, treatment, completion and discharge, during the intake process, in seven of seven outpatient records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In the consent to services the consumer will acknowledge the information regarding the admission to services, which indicates an individual with a substance use diagnosis, treatment procedures that will occur throughout treatment, completion of treatment by achieving all goals and objectives and discharge from the program by successfully completing the program as indicated previously or by unsuccessful discharge by not engaging in treatment or not following agreed upon treatment recommendations. Consent to services are completed at every intake session and on a yearly basis with the therapist. The consumer will be provided the information at the start of the treatment episode and periodically throughout treatment, on a yearly basis. Therapist will be reviewing the criteria for admission, treatment, completion, and discharge at the upcoming sessions in order to address the deficiencies and provide clarity and information to the clients.
Reviews will be completed by the Chief Quality Officer on a monthly basis to address the deficiencies and assure appropriate documentation. The addition to the consent to services occurred on 7.21.2026.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included familiarization with hours of operation in seven of seven outpatient records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In review of the documentation that is provided. The hours of operation will be placed on the information regarding each site that provides Drug and Alcohol services. The hours of operation will be provided to the consumers at the next session to assure that
Dubois
Monday 0800-1800
Tuesday 0800-1800
Wednesday 0800-1800
Thursday 0800-1800
Friday 0800-1700
The information was updated/completed on 7.21.2026 by the Chief Quality Officer. The therapist have been notified regarding information the consumers of the hours of operation. In order to assure this deficiency doesn't occur again the information will be placed in the consent to services. A copy of the consent to services is offered to the consumer at intake and on a yearly occurrence. |