INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2009 through March 13, 2009 by staff from the Division of Drug and Alcohol Program Licensure. 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 and a plan of correction is due on April 5, 2009.
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of the annual report and staff interview on March 12, 2009 and March 13, 2009, the facility failed to make the annual report available to the public within six months of the end of the facility's fiscal year.
The findings include:
According to staff, the facility's fiscal year runs from July first to June thirtieth. The annual report for July 1, 2007 to June 30, 2008 was not yet made available to the public as of the dates of this inspection, which occurred on March 12, 2009 and March 13, 2009.
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Plan of Correction
Effective Monday, March 23, 2009, the annual report was posted on the Child Guidance Resource Centers' website for public review. Child Guidance Resource Centers(CGRC) will make our annual report available to the public within six months of the close of our fiscal year. The Director of Marketing will be responsible to update our annual report and coordinate public awareness and review of annual report via website. The annual report update and coordination of public viewing will be completed by 12/31/09. The Project Director will work with the Director of Marketing to update the annual report and its public posting to ensure compliance. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records on March 13, 2009, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of client information in one of three client records.
The findings include:
Three client records were reviewed on March 13, 2009. Informed and voluntary consents for the disclosure of client information were required in three client records. An informed and voluntary consent for the disclosure of client information to the insurance company was missing in client record #3.
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Plan of Correction
The clinical supervisor will retrain the counselor on how to properly complete and the importance of completing an informed and voluntary consent for the disclosure of client information to the insurance company. This consent will be completed and signed by client at next client visit. The training will be completed through ongoing supervision meetings between Clinical Supervisor and Counselor by 4/10/09. Supervision meetings take place as needed and every Friday morning. The clinical supervisor, medical record staff reviewer and Medical Records Manager will insure continued compliance through monthly client record reviews. |
709.28(c)(3) 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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records on March 13, 2009, the facility failed to document the purpose of disclosure on the informed and voluntary consent for the disclosure of client information in two of three client records.
The findings include:
Three client records were reviewed on March 13, 2009. Informed and voluntary consents with the purpose for disclosure were required in three client records. The purpose for disclosure was missing on the informed and voluntary consent forms in client records #1 and 3.
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Plan of Correction
The clinical supervisor will retrain the counselor on how to properly complete the reason for disclosure on the informed and voluntary consents. The purpose for disclosure will be added to these consents,completed and signed by client #1 and #3 at next client visit. The training will be completed through ongoing supervision meetings by 4/10/09. Supervision meetings are scheduled as needed and every Friday morning. The Clinical supervisor, Medical records reviewer and Medical Records Manager will insure continued compliance through monthly chart reviews/audits. |
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 a review of fire drill records on March 12, 2009 and March 13, 2009, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records were reviewed on March 12, 2009 and March 13, 2009. Fire drills were required to be conducted at least once a month. There was no fire drill conducted in January 2009.
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Plan of Correction
Effective immediately, the Facilities Office Manager will conduct facility fire drills on a monthly basis. The Facilities/Office Manager will be responsible for all documentation of the drills. The Facility Director will be responsible to insure that Facilities/Office Manager conducts and completes appropriate documentation for monthly fire drills. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records on March 12, 2009 and March 13, 2009, the facility failed to maintain a fire drill record to include the date, time, amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records were reviewed on March 12, 2009 and March 13, 2009. The amount of time it took for evacuation was missing on fire drills dated 8/21/08, 12/24/08 and 2/23/09. The exit route used was missing on fire drills dated 8/21/08 and 2/23/09. The operation status of the fire alarm or smoke detector was missing on fired drills dated 7/3/08, 8/21/08, 9/30/08, 11/19/08 and 2/23/09.
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Plan of Correction
Effective immediately, the Facilities Director will retrain the Facilities/Office Manager on how to properly document the date, time, amount it took for evacuation, the exit route used, the number of persons in the facility at time of the fire drill, problems encountered and whether the fire alarm or smoke dectector was operative. The Facility Director will be responsible for monthly review of the completion of the fire drill paperwork. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records on March 13, 2009, the facility failed to include measurable short and long-term goals on the treatment plan in two of two client records.
The findings include:
Three client records were reviewed on March 13, 2009. Treatment plans were required in two client records. The treatment plans did not include measurable short and long-terms goals in client records #1 and 3.
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Plan of Correction
The clinical supervisor will retrain the counselor creating short and long term measurable goals. Treatment plans with measurable short and long term goals were created for clients #1 and #3 and will reviewed with clients and signed at next client visit. The training will take place through supervision between Clinical Supervisor and counselor by 4/10/09. Supervision meetings take place as needed and every Friday morning. The clinical supervisor and Facility Director will insure continued compliance through monthly clinical review of treatment plans. |
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 the review of client records on March 13, 2009, the facility failed to include the type of treatment services on the treatment plan in two of two client records.
The findings include:
Three client records were reviewed on March 13, 2009. Treatment plans were required in two client records. The treatment plans were missing the type of treatment and rehabilitative services in client records #1 and 3.
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Plan of Correction
The clinical supervisor will retrain the counselor on how to document Type of treatment and rehabilitative services on client treatment plans. The type of treatment and rehabilitative services was added to client records #1 and #3. These treatment plans will be reviewed with clients and signed at next client visit. The training will take place through ongoing supervision by 4/10/09. The supervision metings between Clinical Supervisor and counselor take place as needed and every Friday morning. The Clinical Supervisor and Facility Director will be responsible for continued compliance through both initial and monthly treatment plan reviews. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records on March 13, 2009, the facility failed to include proposed types of support services on the treatment plan in one of two client records.
The findings include:
Three client records were reviewed on March 13, 2009. Treatment plans were required in two client records. The treatment plan was missing proposed types of support services in client record #1.
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Plan of Correction
The clinical supervisor will retrain the counselor on how to properly document and include proposed types of support services on all client treatment plans. The proposed types of support was included with treament plan for client #1. This proposed type of support services on treatment plan will be added,reviewed and signed by client at next client visit. The training will take place through ongoing supervision and by 4/10/09. Supervision meetings take place as needed and every Friday morning. The Clinical Supervisor and Facility Director will insure continued compliance through initial and monthly clinical review of all treatment plans. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records on March 12, 2009, the facility failed to document feedback forms on completed training in four of four personnel records.
The findings include:
Four personnel records were reviewed on March 12, 2009. Four personnel records were required to include feedback forms on completed training. Feedback forms on completed training were missing in personnel records #1, 2, 3 and 4.
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Plan of Correction
The Staff Development Coordinator will continuously enforce the use of existing training feedback forms. All personnel will be trained on utilizing these forms by 4/13/09. The Staff Development Coordinator will be responsible for collecting and monitoring the completion of feedback forms for all attended trainings. |
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 the review of personnel records on March 12, 2009, the facility failed to ensure that all staff receive six hours of HIV/AIDS and four hours of TB/STD training within the required time frame in one of three personnel records.
The findings include:
Four personnel records were reviewed on March 12, 2009. Four personnel records were required to have documentation of completion of six hours of HIV/AIDS and TB/STD training. HIV/AIDS and TB/STD training was missing in client record #4. This training for personnel record #4 was due to be completed by January 1, 2009.
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Plan of Correction
Two project personnel are scheduled to attend the mandatory HIV/AIDS on Friday 4/24/09 and TB/STD training on Friday 5/1/09. The Staff Development Coordinator will ensure that all project staff are appropriately registered,trained and documentation is completed on mandatory HIV/AIDS, TB/STD trainings. |