INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2011 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 May 12, 2011.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on April 14, 2011. The facility failed to document any alternate exits used during fire drills. The front door was the exit route used during every fire drill.
This is a repeat citation from the 03-30-2010 license renewal inspection. An interview with the administrative staff at 11:00 confirmed the facility did not use alternate routes during twelve months of fire drills.
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Plan of Correction
Although alternate fire exits are used but were not documented,effective immediately and with April 2011 drill fire drill conducted, Facilities Manager ensured that alternate exit routes were used and documented.
Staff will be retrained on fire drill practice in supervision and staff meetings. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to have the project policies, that included client rights, presented to the client upon admittance to the program, in one of three client records.
The findings include:
The three client records were reviewed on April 14, 2011. All records were required to provide documentation that clients rights had been reviewed with each patient at the time of admission. A patient, upon review of client rights, signs a form attesting to the fact that client rights have been reviewed. Client record # 2 did not contain documentation that verified that the client had received information regarding client rights. An interview with the administrative staff during the exit interview confirmed the client was admitted on February 8, 2011 but the client rights form was not signed by the client until April 4, 2011.
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Plan of Correction
The clinical supervisor will retrain the clinician on presenting and completing signature requirement on Client Rights information upon intake (1st visit) into program. The training will be completed through ongoing supervision meeting between clinician and clinical supervisor by May 27,2011
The clinical supervisor, medical record reviewer will ensure 100% compliance during monthly chart reviews. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records and staff interviews, April 14, 2011, the facility failed to provide documentation of the client's signature on the orientation form that attested they had received orientation information in one of three client records.
The findings included:
Three client records were reviewed on April 14, 2011. All records were required to provide documentation that the client was provided orientation information at the time of admission. Client #2 was admitted on February 08, 2011; the documentation reviewed revealed that the orientation form was not signed until April 05, 2011. An interview with the administrative staff at 3:00 PM on April 14, 2011, confirmed the facility failed to complete the orientation documentation upon admission..
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Plan of Correction
The clinical supervisor will retrain the clinician on presenting and completing signature requirement on receiving orientation information upon intake (1st visit)and/or admission into program. The training will be completed through ongoing supervision meeting between clinician and clinical supervisor by May 27,2011 The clinical supervisor, medical record reviewer will ensure 100% compliance during monthly chart reviews.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service that included a chronological listing of all services provided to the client in two of three client records.
The findings include:
Three outpatient client records were reviewed on April 14, 2011. A record of service including all services provided to the client was required in three client records. The facility failed to document a complete record of service in client records #1, and 2
Record #1 had progress notes documented for 03-10-2011 No record of service was documented for this service.
Record #2 had progress notes documented for 04-12-2011 No record of service was documented for this service.
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Plan of Correction
The clinical supervisor will retrain the clinician on presenting and completing a chronological listing of services matching progress notes for every service visit. The training will be completed through ongoing supervision meeting between clinician and clinical supervisor by May 27,2011 The clinical supervisor, medical record reviewer will ensure 100% compliance during monthly chart reviews.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and an interview with the clinical director, the facility failed to document progress notes in two of three client records.
The findings include:
Three client records were reviewed on April 14, 2011. Three of the client records were required to have progress notes. Per the facility policy, progress notes are required to be completed after each significant contact. The facility failed to document progress notes in client records #1 and 2.
In client record # 1, the record of service has documentation that states the client received service on 04-04-2011. The facility failed to document a progress note reflecting this counseling session.
In client record #2, the record of service has documentation that stated the client received service on 02-22-2011. The facility failed to document a progress note to reflect that this counseling session had occurred.
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Plan of Correction
The clinical supervisor will retrain the clinician on completing progress notes for every service visit provided. The training will be completed through ongoing supervision meeting between clinician and clinical supervisor by May 27,2011 The clinical supervisor, medical record reviewer will ensure 100% compliance during monthly chart reviews.
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