INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
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Plan of Correction
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of five applicable records reviewed.
Client #3 was admitted on March 7, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 6, 2022 and the next update was due no later than July 6, 2022; however, it was not completed at the time of the inspection.
Client #5 was admitted on April 15, 2021 and discharged July 8, 2022. A treatment plan update was completed on March 21, 2022 and the next update was due no later than May 21, 2022; however, it was not completed at the time of the inspection.
Client #6 was admitted on January 14, 2022 and discharged on May 17, 2022. A treatment plan update was completed on February 11, 2022 and the next update was due no later than April 11, 2022; however, it was not completed at the time of the inspection.
Client #7 was admitted on February 11, 2022 and discharged May 17, 2022. A treatment plan was completed on February 25, 2022 and the next update was due no later than April 25, 2022; however, it was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The OP Director or the D&A Supervisor will provide the therapist will be provided end dates for treatment plans and provided a list of consumer's on their caseload with treatment plan update dates. They will be provided this on a monthly basis. The OP Director or D&A Supervisor will follow up with the therapist in regards to the treatment plan updates. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the regulatory timeframe in six out of six applicable client records. The facility's policy and procedures manual states case consultations will be completed every 90 days. No case consultations were completed.
Client #2 was admitted on March 16, 2022 and was still active at the time of the inspection.
Client #3 was admitted on March 7, 2022 and was still active at the time of the inspection.
Client #4 was admitted on March 28, 2022 and was still active at the time of the inspection.
Client #5 was admitted on April 15, 2021 and was discharged on July 8, 2022.
Client #6 was admitted on January 14, 2021 and discharged on May 17, 2021.
Client #7 was admitted on February 11, 2022 and was discharged on May 17, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The OP Director or D&A Supervisor will provide a list of case consults to the therapist for consumers that need case consults. Case consultations will be completed by the therapist every 3 months. D&A Supervisor or OP Director will sign off on. OP Director or D&A Director will follow up on the case consults that have not been completed by the due dates. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of one applicable discharged records reviewed.
Client #6 was admitted on January 14, 2021 and was discharged on May 15, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A follow up letter will be sent out to the consumer by the administration secretary. A note will be made in the client chart that the letter was sent out to the consumer. Follow up by the Administration supervisor to assure that letters have been send out. |