INITIAL COMMENTS
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This report is a result of an off-site investigation conducted on March 30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the off-site investigation, 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 investigation and a plan of correction is due on April 23, 2010.
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Plan of Correction
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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 a review of two personnel records and discussion with the staff, it was determined that the facility failed to ensure that staff members completed a feedback form on all training attended.
The findings were:
A review of two of two personnel records, specifically records #1 and 2, on March 30, 2010 indicated that feedback forms were not completed for all training attended.
An interview with the facility staff confirmed that staff members #1 and 2 did not complete feedback forms for all training attended This a repeat citation.
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Plan of Correction
Child Guidance Resource Center's Training Coordinator in colloboration with Facility Director will develop a specific training feedback form to be used by all Drug & Alcohol employees. The form will developed by 5/15/10. This form will enable all D&A program employees to provide feedback on all internal and external trainings they have participated in. The Facility Director and CGRC Training Coordinator will monitor compliance of the form usage and completion |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility staff CPR/first aid certification cards, the facility failed to produce the records of persons trained in CPR and first aid onsite during the project's hours of operation.
Findings:
During the March 30, 2010, onsite investigation, documentation of records to identify staff CPR/first aid certification was requested. The facility failed to provide the documentation. Due to the lack of information, the determination regarding coverage by staff trained in first aid and CPR could not be made.
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Plan of Correction
Child Guidance Resource Center's Drug & Alcohol program does employ a sufficient number of employees CPR/First Aid certified. Program will fax CPR/First Aid cards as instructed to Dept. of Health representative by 4/26/10. CGRC Training Coordinator will be responsible to ensure CPR/First Aid documentation is evident in all program HR files. CGRC training coordinator will track via spreadsheet evidence of CPR/First Aid training on an ongoing basis for all D&A program employees. |
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 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 March 30, 2010. The facility did not document any alternate exit used during fire drills. The front door was the exit route used during every fire drill. The facility has four exit routes that are in use.
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Plan of Correction
All agency fire drills are conducted on a monthly basis. All fire exits are used during these drills. Enviornment of Care representative for D&A program floor will be responsible to document all exits used during drills. Facility Director will work with Environment of Care representative by 5/1/10 to properly and adequately document and educate on using alternative exits during all fire drills. Facility Director will monitor and review all fire drill documenation on a monthly basis. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document medical histories in two of three client records.
The findings include:
Three outpatient client records were reviewed on March 30, 2010. Per agency policy, medical histories are to be completed within fifteen days of admission. Medical histories were required in two client records. The facility did not document medical histories in client records # 2 and 3.
Client # 2 was admitted on 01-28-2010. The medical history of the client and the family were not documented in this client record.
Client # 3 was admitted on 01-14-2010. The medical history did not include family medical history in the client record.
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Plan of Correction
Medical histories will be completed in all D&A program client charts within 15 days of admission. D&A Counselor will be responsible and will be trained by 5/15/10 to complete medical histories with all clients. Clinical Supervisor and Facility Director will review all paperwork for clinical appropriateness and completion including medical histories on an ongoing basis.Clinical Supervisor and Facility Director will monitor compliance with D&A counselor during supervision and ongoing as appropriate. |