INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 6, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Child Guidance Resource Centers 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(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 personnel records, the facility failed to ensure a written individual training plan for each employee was developed annually with the input from both the employee and the supervisor in two of two personnel records reviewed.
The findings include:
Two personnel records requiring individual training plans were reviewed on April 6, 2015. The facility failed to document that the individual training plans were developed with the input of the employee and the supervisor in personnel records #1 and 2.
Employee #1 was hired into the project on April 17, 2007 and was promoted to facility director/clinical supervisor on September 1, 2008. The employee's individual training plan was completed on December 15, 2014; however, there was no employee and supervisor signatures on the training plan. Additionally, there was no other documentation in the employee record indicating that the training plan was developed with the employee.
Employee #2 was hired into the project on June 4, 2009 and into the position of counselor on June 13, 2009. The employee's individual training plan was completed on December 15, 2014; however, there was no employee and supervisor signatures on the training plan. Additionally, there was no other documentation in the employee record indicating that the training plan was developed with the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 and Employee #2 will have current individual training plans signed by 4/24/2015. Employee # 1 and Employee #2 will demonstrate as evidenced by signature the collaboration and coordination when meeting and developing a training plan on or before 12/15/15. The Facility Director, Administrative Director in coordination with the CGRC Training Coordinator will be responsible for development and ongoing monitoring of individual training plans with Employee #1, Employee #2 and all employees and make sure that individual training plans are developed with all parties input, signed and documented annually on time for all employees. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes aftercare plans and follow-up information in two of three client records reviewed.
The findings include:
Three client records, requiring documentation of a complete client record on an individual, were reviewed on April 6, 2015. The facility did not provide a complete client record, which was to include aftercare plans and follow-up information for clients #1 and 3.
Client #1 was admitted to treatment on June 14, 2013 and was discharged to a higher level of care on June 6, 2014. The facility failed to document follow-up information in the client's record as of the date of the inspection.
Client #3 was admitted to treatment on May 1, 2014 and was successfully discharged on February 24, 2015. The facility failed to include signed documentation of the client's aftercare plan in the client's record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor will enter Follow up information for Client#1 by 4/24. All clients follow-up information will be entered in client chart by counselor prior to discharge or transfer to another level of care. Clincial Supervisor/Facility Director will be responsible for counselor training and ongoing monitoring and completion of the documents pripr to cient discharge or client transfer.
Clinicial Supervisor/Facility Director will be responsible for training and on going monitoring with Counselor to complete a signed after care plan for each client prior to discharge. |