INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The facility failed ensure that there was proper ventillation by either an exhaust fan or a window in the two bathrooms located in the lobby. The exhaust fans were inoperable and both of the bathrooms did not have windows.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Although the CGRC bathroom is not equipped with an exhaust fan, it has a fully operational return vent as part of its HVAC system. The system is maintained so that proper air circulation and ventilation occurs. (Our Facilities Manager will obtain this statement on letterhead from our HVAC contractor as verification if needed). |
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
The facility failed to document the time of the drill, the amount of time it took for the evacuation, the number of persons in the facility at the time of the drill, and whether the fire alarm or smoke detector was operative on the May 2017, July 2017, October 2017, November 2017, March 2018, April 2018, May 2018, July 2018, August 2018, November 2018, January 2019 and February 2019 fire drill logs for the reviewed period of April 2017 through February 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drill form will be revised to highlight the evacuation times section and all staff doing drills will be retrained.
The Facilities Manager will review the forms monthly and verify that evacuation times are entered and that evacuation occurs within an acceptable time limit (2mins, 30 seconds). If in any instance evacuation information is incomplete, the drill will be redone. If time of evacuation does not meet standard, the Facilities Manager will ensure that corrective action is documented and implemented.
All drills will be reviewed monthly at the Environment of Care Committee which includes representation from Outpatient Drug and Alcohol program. This committee will report on the status of compliance with drill requirements and other fire safety standards to the Operations group on a quarterly basis at minimum.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the inspection, our financial audit was in process of being finalized by our public accountant. Our Controller will follow agency protocols for completion of the financial audit annually. Our process is as follows:
1. June 30th our fiscal year ends
2. Auditors complete field work the last week in August
3. The auditors complete some testing through September
4. Auditors need to gather information from applicable counties pertaining to federal funding that we receive ? there is no time frame for this and we are dependent on the counties to get this information to us
5. Once that is complete they can work on completing the final report.
Our Controller will ensure completion of the audit annually. This year's audit is expected to be completed by 4/30/19.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that all personnel records contained documentation that the annual written individual performance evaluation was reviewed and signed by the employee in two records reviewed.
Employee # 1 was hired as the Project Director on September 1, 2018. The annual written individual performance evaluation dated December 2018, did not include an employee signature.
Employee # 3 was hired as a counselor on August 1, 2016. The annual written individual performance evaluation dated February 1, 2019, did not include an employee signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will review expectations regarding timeliness of obtaining staff signatures on performance evaluations. |
709.34 (a) (2) 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:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility failed to develop and implement a policy and procedure that identifies the facility's response to the selling or use of illicit drugs on the premises. This was based on a review of the facility's policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement will update the incident management policy and procedures to address response to Selling or use of illicit drugs on the premises. |
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
The facility failed to include in their policy and procedure manual how the facility would respond to an event that requires the presence of ambulance personnel at the facility. This is based on a review of the facility's policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement will update the incident management policy and procedures to address response to an event that requires the presence of ambulance personnel at the facility. |
709.34 (a) (8) 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:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
The facility failed to develop and implement a policy and procedure that identifies how the facility would respond to any incident of a contagious disease outbreak that requires CDC notification. This was based on a review of the facility's policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement will update the incident management policy and procedures to address outbreak of a contagious disease to include notification of the Center for Disease Control. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to include in their policy and procedure manual, specific procedures detailing the process of ongoing monitoring of an unusual incident's corrective action plan. This was based on the review of the facility's policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement will update the incident management policy and procedures to address process of ongoing monitoring of an unusual incident's corrective action plan. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
The facility failed to include, in their policy and procedure manual, the specific procedures on what reporting mechanisms would be put into place that ensures that the confidentiality of client-identifying information is in compliance with State and Federal confidentiality laws. This was based on a review of the facility's policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement will update the incident management policy and procedures to address what reporting mechanisms are in place that ensures that the confidentiality of client-identifying information is in compliance with State and Federal confidentiality laws. |