INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Coomunity 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. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on review of the personnel records, the facility failed to assure that employee # 4 had completed 25 hours of required training. Employee #4 was hired on January 10, 2018 and was still an employee at the time of the inspection. Employee #4 completed 19.5 hours during the training year of July 1, 2020 through June 30, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Clinical Supervisor will assign trainings to be completed on the Relias (Learning Management System). Trainings will be completed on a monthly basis to assure that each employee has accumulated 25 hours of training each year. |
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 August through December 2019, March and April of 2020 and January through July 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 completed monthly then scanned in and then sent to the Chief Operations Officer and placed in a binder for review and records retention. |
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 28, 2021, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one out of the seven client records reviewed.
Client #7 was admitted on March 23, 2021 and discharged on May 19, 2021. The facility had an informed and voluntary consent for a governmental agency dated February 24, 2021 with no client signature due to COVID and the facility has contact with the governmental agency via a letter on March 3, 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 28, 2021, the facility failed to document that the client was offered a copy of the informed and voluntary consent to release information.
Client #5 was admitted on December 31, 2019 and was discharged on Aril 2, 2020. There were eleven 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. It will be noted on the release of information if the consumer refused or rejected a copy of the release. Consumer will initial the release either accepting 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 28, 2021, the facility failed to obtain a written signed consent to treat from the client.
Five out of seven client records reviewed did not have documentation that the client signed a consent to treat form.
Client #1 was admitted on May 3, 2021 and was an active client at the time of the inspection.
Client #2 was admitted on April 28, 2021 and was an active client at the time of the inspection.
Client #3 was admitted on March 29, 2021 and was an active client at the time of the inspection.
Client #4 was admitted April 20, 2021 and was an active client at the time of inspection.
Client #7 was admitted on March 23, 2021 and was discharged on May 19, 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 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(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records during the inspection on July 28, 2021, the facility failed to document frequency of counseling services on comprehensive treatment plans in four out of seven client records.
Client # 2 was admitted on April 28, 2021 and was an active client at the time of the inspection. Comprehensive treatment plan dated May 6, 2021.
Client #4 was admitted April 20, 2021 and was an active client at the time of inspection. Comprehensive treatment plan dated May 12, 2021.
Client #6 was admitted on September 22, 2020 and discharged on May 28, 2021. Comprehensive treatment plan dated April 5, 2021.
Client #7 was admitted on March 23, 2021 and was discharged on May 19, 2021. Comprehnsive treatment plan dated April 19, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Community Guidance Center's Drug and Alcohol Supervisor will review and assure that the frequency of service is stated in the Comprehensive Treatment Plan. The assigned therapist will complete the comprehensive treatment plan with the consumer via in person or telehealth in the first session. |
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. |