INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2023 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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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures which included the response to an event at the facility requiring the presence of police, fire or ambulance personnel.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy of the Community Guidance Center involving critical incidents has been updated to reflect in events of emergency the facility will require the presence of police, fire, or ambulance. The policy had was updated on 7.26.2023. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #1 was admitted on April 20, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 5, 2023 and an update was due no later than July 5, 2023; however, none was completed.
Client #3 was admitted on February 15, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 6, 2023 and an update was due no later than May 6, 2023; however, it was not completed until May 26, 2023.
Client #4 was admitted on February 10, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 3, 2023 and the next update was due no later than July 3, 2023; however, none was completed.
Client #5 was admitted on August 25, 2022 and was discharged on May 31, 2023. A comprehensive treatment plan was completed on September 19, 2022 and an update was due no later than November 19, 2022; however, it was not completed until December 2, 2022. Additionally, the next update was due no later than February 2, 2023; however, it was not completed until March 24, 2023.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 14, 2022 licensing inspection.
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Plan of Correction
The treatment plans are being audited monthly by supervisor, director, chief quality officer. Therapist will be completing treatment plans 7 days ahead of when they are expired. Therapist were informed of this on 7/14/2023 about the expectations for the service plans. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #4 was admitted on February 10, 2023 and was still active at the time of the inspection. A case consultation was due no later than May 10, 2023; however, it was not completed until May 15, 2023.
Client #5 was admitted on admitted on August 25, 2022 and discharged on May 31, 2023. A case consultation was completed on December 2, 2022 and the next one was due no later than March 2, 2023; however, it was not completed until March 8, 2023.
Client #6 was admitted on September 27, 2022 and was discharged on April 6, 2023. A case consultation was due no later than December 27, 2022; however, it was not completed until January 17, 2023.
Client #7 was admitted on October 7, 2022 and was discharged on January 17, 2023. A case consultation was due no later than January 7, 2023; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Case consults will be audited monthly by the supervisor, director, and chief quality officer. Therapist were informed that case consults will be completed with each treatment plan to assure accurate and timely feedback. Therapists were informed of this on 7/19/2023. |
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 within guidelines established by the facility's policy and procedures manual in two out of two applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 30 days following discharge.
Client #6 was admitted on September 27, 2022 and discharged on April 6, 2023. A follow up was due no later than May 6, 2023; however, it was not completed until May 23, 2023.
Client #7 was admitted on October 7, 2022 and was discharged on January 17, 2023. A follow up was due no later than February 17, 2023; however, it was not completed until February 21, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The follow up report will be run weekly instead of bi-weekly to ensure follow-ups are being send within the 30 days. D&A Supervisor is going to track these. Correction of the report occurred on 7/26/2023. |
709.43(b)(3) LICENSURE Communicable diseases
709.43. Client management.
(b) The intake project shall have written policies and procedures to address special issues regarding treatment of clients. These policies and procedures shall include, but are not limited to:
(3) Individuals with communicable disease.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures to address special issues regarding treatment of clients, to include individuals with communicable disease.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The exposure control policy was revised on 7/24/2023 to reflect how to address special issues and regarding the treatments of clients, to include individuals with communicable diseases and referrals resources. |