INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 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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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 personnel records, the facility failed to ensure two employees received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment in two of three records.
Staff #3 was hired as a counselor on April 11, 2023 and still employed at time of inspection. Staff #3 was due to have the communicable disease trainings no later than April 11, 2024. The TB/STD training was completed late on July 11, 2024.
Staff #5 was hired as a counselor on February 6, 2023 and still employed at time of inspection. Staff #5 was due to have the communicable disease trainings no later than February 6, 2024. There was no documentation provided of the completion of the HIV/AIDS training as of the date of the inspection and TB/STD was completed late on July 11, 2024.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff members will be assigned to required DDAP trainings within the first year. These will be assigned through the Electronic Training System (Relias) that is used at the CGC. These trainings will be made mandatory to complete by for staff to complete the employee within the first year of their employment. Trainings will be assigned by the D&A Director, D&A Supervisor, or HR Director at the time of hire to assure that trainings are completed in timely manner. |
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 a review of the personnel training records, the facility failed to have the counselor complete at least 25 clock hours of annual training in one of three records.
Employee #5 was hired as a counselor on February 6, 2023 and still employed. Employee #5 documented 18 hours of training for the July 1, 2023 to June 30, 2024 training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annually required DDAP tTrainings will be assigned to therapists through the Electronic Training System (Relias) used at the CGC.
Specifically, ten (10) hours of training will be assigned to each therapist to complete throughout the yearannually by the D&A Director, D&A Supervisor, or HR Director.
Fifteen (15) additional hours of annual training will be required by therapists; which may be completed by way of external (outside of the agency) or internal (within the agency) trainings. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days.
The facility had an unusual incident occur on April 26, 2024 which involved death of a client. The facility had not submitted a written unusual incident report to the Department at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Unusual Incident Reports will be reviewed by the Chief Clinical Officer or Chief Quality Officer and then be sent to the appropriate entity.
Each incident/report will be reviewed and if one of the criteria is met the report will then be sent to the Department of Drug and Alcohol Programs for notification.
To assure that unusual incidents are processed accordingly, a multistage approval is needed in the Electronic Health Record in order to complete the document. The service(s)s will be completed by the therapist/counselor, then reviewed and signed by the Director/supervisor, and then finally reviewed and signed by the Chief Clinical Officer or Chief Quality Officer.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days.
The facility had an unusual incident occur on August 16, 2023 which involved police onsite. The facility had not submitted a written unusual incident report to the Department at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Unusual Incident Reports will be reviewed by the Chief Clinical Officer or Chief Quality Officer and then be sent to the appropriate entity.
Each incident/report will be reviewed and if one of the criteria is met the report will then be sent to the Department of Drug and Alcohol Programs for notification.
To assure that unusual incidents are processed accordingly, a multistage approval is needed in the Electronic Health Record in order to complete the document. The service(s) will be completed by the therapist/counselor, then reviewed and signed by the Director/supervisor, and then finally reviewed and signed by the Chief Clinical Officer or Chief Quality Officer. |
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 #5 was admitted on February 12, 2024 and was discharged on May 6, 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 11, 2023 licensing inspection.
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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. |