INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 2024 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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705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on a review of administrative information, the facility failed to provide written procedures for the staff and clients to follow in case of an emergency to include the evacuation and transfer of clients and staff to a safe location.
The policy and procedure manual did not include the Northern Cambria site on the emergency meeting place list.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Chief Quality Officer has updated the Emergency/Disaster procedures policy and plan has been updated to reflect the emergency meeting place for the Northern Cambria Location. The meeting place has been identified as the Barrett Funeral home parking lot. The Director and Supervisor will ensure that the emergency location is placed in the office per CGC policy. Safety Committee will look at emergency relocations for the site every year. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation of the disclosure of all the required client rights, including the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in two of three records.
There was no documentation of this disclosure in either of the following client records.
Client #1 was admitted on January 22, 2024 and was still active at the time of the inspection.
Client #3 was admitted on December 13, 2023 and discharged on May 15, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Chief Quality Officer and the Director updated the consent to services to reflect the addition of the following language:. "The provisions of services and referrals of clients shall be made without regard to age, race, color, religion, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion.". The update that was made is a required field in order to complete the service. This will be reviewed with the consumers at intake and yearly. The consent of services will be monitored by the Chief Quality Officer during the monthly Drug and Alcohol department audits. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in one of two discharged records.
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 30 days.
Client #3 was admitted on December 13, 2023 and was discharged on May 15, 2024. There was no follow up information documented in the client record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 12, 2023 and July 20, 2022 annual licensing inspections.
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Plan of Correction
The primary audit is completed by the IT Tech and the D&A Supervisor on a weekly basis. If the IT Tech is not present the IT Director will step in and run the one (1) month and six (6) month follow up reports. The Chief Quality Officer will complete the one (1) month and six (6) month follow up reports and audit to ensure the follow up letters are being sent in a timely manner. This is an additional audit that is occurring. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for client follow ups were submitted and approved by the Department for the July 12, 2023 and July 20, 2022 annual licensing inspections. Client follow ups was again found to be a deficiency in the July 23, 2024 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Corrections will be followed moving forward by additional audits and an open discussion in Quality Assurance Meetings and also during the Professional Advisory Committee meeting to ensure the Community Guidance Center is following the POC that is in place. Chief Quality Officer and Director will lead this discussion in the committee meetings to ensure the POC is followed. |