INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 1, 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, Community Guidance Center 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.
|
Plan of Correction
|
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
The facility failed to document that the project director had prepared, annually updated and signed a written policy and procedure manual for 2018 based on a review of the facility's policy manual on July 30, 2019.
The policy and procedure manual was last signed off by the project director on July 31, 2017.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
- During the year of 2018, the Community Guidance Center experienced a shift in management including a change in the Project Director. Due to the shift in management, a breakdown of processes occurred causing the D&A policy and procedure manual to not be reviewed, updated, and signed. Before this year and for the current year, the Center has been in compliance with this requirement.
To prevent a breakdown of future processes, the D&A policy and procedure manual will be maintained and stored with the overall Center policy and procedure manual to allow for its annual review by the Board of Directors, CEO, and Project Director in the Fall of every year as is the current agency process. To reduce human error and ensure compliance, the Center's internal Relias training/ tracking system will be utilized to ensure the completion of this task.
Effective 10/1/19, the Relias tracking system will be updated to send an automated email reminder to the Project Director and Facility Director directing them to ensure the review, update, and signature of the policy manual for that year. Once the task has been completed, both the Project and Facility Director will enter the date of completion into the Relias tracking system marking the task as completed. The Project and Facility Director will receive automated messages via email of the task due date annually moving forward. They will begin receiving the messages 3 months before due date (July 1) to allow time to have the manual reviewed and signed by all required before the due date of October 1. The automated messages will continue to be sent until the task is completed. The automated messages and compliance with 709.23 will be overseen by the Project Director, Facility Director, and HR specialist responsible for the maintenance of the Relias system.
|
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
The facility failed to document a client rights policy that included all of the client rights based on a review of the facility's policy and procedure manual on July 30, 2019.
The facility's client rights policy did not include the following: "the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines the information may be detrimental if presented to the client and reasons for removing sections shall be documented in the record".
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
- To ensure compliance with the corrective action plan, the Informed Consent policy will be established to include all D&A rights and responsibilities. The updated Informed Consent policy with the inclusion of the D&A rights and responsibilities will be completed and implemented as policy by 10/1/19. |