INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Guidance For Growing, LLC 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 14, 2011.
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Plan of Correction
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709.22(d)(2) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(2) Identifying the project's purpose and philosophy.
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Observations
Based on an interview with the project director, the facility failed to provide a policy identifying the project's purpose and philosophy.
The findings include:
On April 11, 2011 the Licensing Specialist asked to see the facility's policy identifying the project ' s purpose and philosophy. A policy identifying the project ' s purpose and philosophy was not presented for review.
An interview with the project director conducted on April 11, 2011 confirmed that the facility did not have a policy identifying the project's purpose and philosophy.
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Plan of Correction
A policy identifying the project ' s purpose and philosophy will be completed by the project director by 5/15/2011. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility ' s policies and procedures manual and an interview with the project director, the facility failed to have the project director sign the manual indicating a review and update of the written manual delineating project policies and procedures.
The findings include:
The facility ' s policies and procedures manual was reviewed on April 11, 2011. The facility failed to have the project director sign the manual indicating a review and update of the written manual.
An interview with the project director conducted on April 11, 2011 confirmed that the facility failed to have the project director sign the manual indicating a review and update of the written manual.
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Plan of Correction
The project director will make a 'review and update' page located in the front of the policy manual. The project director will sign off annually on the 'review and update' page. This will be completed by 5/15/2011. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of the facility ' s administrative documentation and interview with the project director/facility director, the facility failed to develop goals and objectives for 2010 to 2011.
The findings include:
The facility ' s administrative documentation was reviewed on April 11, 2011. The facility was required to develop goals and objectives for 2010 to 2011. The facility did not develop goals and objectives for 2010 to 2011. The last goals and objectives for the facility were for September 2009 to February 2010.
An interview with the project director/facility director conducted on April 11, 2011 confirmed that the last goals and objectives for the facility were for September 2009 to February 2010.
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Plan of Correction
The facility director will be responsible for facility goals and objectives, which will be completed every September. The goals will be both short and long term goals. Goals will be reviewed yearly, every September. Goals will be completed by 4/15/2011, which will be reviewed and revamped 9/2011. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records and an interview with the project director, the facility failed to provide documentation that the facility ' s alarm is in working order.
The findings include:
Fire drill records were reviewed on April 11, 2011. The records were reviewed for the period covering March 2011. The facility was granted an approval on September 7, 2010 to the Physical Plant Standards for Nonresidential Facilities, Chapter 705.28 (d) (7), relative to activating a fire alarm or smoke detector during a fire drill. As a result of the approval, the facility was required to provide documentation that their fire alarm is in working order. Documentation that the facility ' s fire alarm is in working order was not presented for review.
An interview with the project director conducted on April 11, 2011 confirmed that the facility did not have documentation that their fire alarm is in working order.
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Plan of Correction
The facility director will contact the building owner to receive documentation of working fire alarm system. This will happen by 5/15/2011 and will from here forward be done once contacted for yearly licensing visits. This will ensure documentation will be present for the scheduled visits. |
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 and an interview with the project director, the facility failed to document a medical history that included a family medical history, family symptoms, and family illness in one of one client record reviewed.
The findings include:
On April 11, 2011, one client record was reviewed for documentation of a medical history. The facility failed to document a medical history that included a family medical history, family symptoms, and family illness in client record # 1.
The facility ' s policy titled: " Treatment/Rehabilitation Management, " states:
"The bio-psychosocial assessment will include histories on:
Medical History: Documents the client ' s personal medical history, family medical history, history of illness, symptoms, and any medications currently being taken. "
Client # 1 was admitted on March 26, 2011. The medical history was completed on April 2, 2011, but it did include a family medical history, family symptoms, and family illness.
An interview with the project director on April 11, 2011 confirmed that the medical history in client record # 1 did not include a family medical history, family symptoms, and family illness.
This is a repeat citation. The facility was cited on February 23, 2011 on medical history:
The facility ' s Plan of Correction for the February 23, 2011 citation was as follows:
"The clinical supervisor is reviewing a new assessment tool provided the licensing specialist that performed the inspection. The assessment tool contains sections that require input for family history of illness or a symptoms and illness checklist. The clinical supervisor will implement this tool or create an addendum to the current assessment tool that will address the missing information. "
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Plan of Correction
The facility director will create a new page for the questionnaire that will include needed information for family medical history, family symptoms and family illness. This will be completed by 5/15/2011 and will be inserted as part of the intake questionnaire. |
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 a review of client records and an interview with the project director, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan in one of one record reviewed.
The findings include:
On April 11, 2011, one client record was reviewed for documentation for short and long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan. The facility did not document the short-term goals for treatment in client record # 1.
The facility ' s policy titled: " Treatment and Rehabilitation Services, " states:
" (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. Goals should be realistic and stated in terms of measurable criteria. "
Client # 1 was admitted on March 26, 2011. The individual treatment and rehabilitation plan was completed on April 2, 2011 but did not include documentation for the short-term goals for treatment.
An interview with the project director on April 11, 2011 confirmed that the individual treatment and rehabilitation plan in client record # 1 did not include documentation for the short-term goals for treatment.
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Plan of Correction
The project director will now have all treatment plans with short in long term goals in the individualized treatment plan template. This will insure that all treatment plans (to be filled in completely) must contain short and long term goals. This will be monitored by the project director and will be implemented immediately. |
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 a review of client records an interview with the project director, the facility failed to document the frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in one of one client record reviewed.
The findings include:
On April 11, 2011, one record was reviewed for documentation for type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan. The facility did not document the frequency of treatment and rehabilitation services in client record # 1.
The facility ' s policy titled: " Treatment and Rehabilitation Services, " states:
" (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. Goals should be realistic and stated in terms of measurable criteria.
(2)Type and frequency of treatment and rehabilitation services.
Examples - group counseling twice a week, family therapy every three weeks, biofeedback bi-weekly. "
Client # 1 was admitted on March 26, 2011. The individual treatment and rehabilitation plan was completed on April 2, 2011, but did not include documentation for the frequency of treatment and rehabilitation services.
An interview with the project director on April 11, 2011 confirmed that the individual treatment and rehabilitation plan in client record # 1 did not include the frequency of treatment and rehabilitation services.
This is a repeat citation. The facility was cited on February 23, 2011 on frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan.
The facility ' s Plan of Correction for the February 23, 2011 citation was as follows:
" The clinical supervisor will add a section in the individualized treatment plan template that will include line for frequency of sessions. This will be completed by 4/10/2011. "
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Plan of Correction
The project director will amend the template used for individualized treatment plans will include a section for Type: and Frequency: of services offered. This will be completed by 5/15/2011. |