INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. 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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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of a personnel record, the Chief Executive Officer's job description, and the project's organizational chart, the facility failed to have a project director responsible for the overall management of the project and staff in one of one personnel record reviewed.
The findings include:
On April 8, 2013, one personnel record, the Chief Executive Officer's job description, and the project's organizational chart were reviewed. The facility failed to have a project director responsible for the overall management of the project and staff in one of one personnel record reviewed, specifically, employee # 1.
Employee # 1, the project director, was initially hired by the project November 14, 2000 and hired for his current position on September 1, 2008. A review of employee # 1's job description indicated that he is the Chief Clinical Officer but not responsible for the overall management of the project and staff. The job description indicated that under the direction of the Chief Executive Officer, employee # 1 designs, directs, supervises, and coordinates the CGRC delivery of care services to children, adolescents, and their families in all CGRC levels of care including Early Childhood, Family Based, MST, Truancy, Behavioral Health Rehabilitative Services, STAP, EAS, Case Management, After School, and School-Based. A review of the project's organizational chart further confirmed that employee # 1 is not responsible for the overall management of the project and staff. The chart indicated employee # 1 is responsible for the project's CYS Services, Delaware State Services, Detention Center Services, Family Based Services, and Outpatient Clinical Services Drug and Alcohol Program.
However, a review of the Chief Executive Officer's job description indicated that he is the one responsible for the overall management of the project and staff. The job description indicated that through the policies and procedures established by the Board of Directors, the Chief Executive Officer has overall responsibility for the effective management of Child Guidance Resource Centers. The job description further indicates that the Chief Executive Officer plans, directs, and oversee the operations of the organization. In addition, the project's organizational chart further confirmed that the Chief Executive Officer is responsible for the overall management of the project. The chart indicated that the Chief Executive Officer reports to the Board of Directors and is the one responsible for the overall management of the project and staff.
The findings were confirmed during an interview with the Administrative Director of Out-Patient Services on April 8, 2013 at approximately 10:30 A.M.
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Plan of Correction
A letter has been drafted by Administrative Director, Outpatient Services dated 5/3/13 and will be sent via fax to Acting Director, Division of Program Licensure to request an exception to have the Project Director to be the CCO. If an exception is not granted by the Division of Program Licensure, PA Dept. of Drug and Alcohol Programs by 6/30/13, our program will be in full compliance. Our Division Director of Performance Improvement will be responsible for on-going monitoring of the staffing regulations of this program. We will ensure full compliance with this regulation by having CEO as the Project Director. The President of the Board of Directors will ensure that CEO remains in place as the Project Director. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the administrative material, the facility failed to make available to the public an annual report that included a financial statement of income and expenses.
The findings include:
The administrative material was reviewed on April 8, 2013. The document presented at the time of review as the annual report for the facility's July 1, 2011 to June 30, 2012 fiscal year did not include a financial statement of income and expenses.
The findings were confirmed during an interview with the Administrative Director of Out-Patient Services on April 8, 2013 at approximately 10:30 A.M.
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Plan of Correction
A financial and expense statement which is a part of the CGRC Annual Report will be made available to the public via a link added to the Child Guidance Resource Center's website by our web master. This link will be available by 05/31/13. In addition; the income and expense report link will be posted annually by webmaster. Our Division Director of Performance Improvement will be responsible for the ongoing and annual moniotring of this posting. |
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 a review of client records, the facility failed to document a subsequent case consultation in one of one client record reviewed.
The findings include:
The facility's policy titled: "Client Records," states:
"Case consultations are completed quarterly on clients in treatment for one year or less."
On April 8, 2013, one client record requiring documentation of case consultation was reviewed. The facility did not document a subsequent case consultation in one of one record reviewed, specifically, client record # 1.
Client # 1 was admitted June 18, 2012 and discharged January 24, 2013. The case consultation was completed September 19, 2012. The subsequent case consultation due December 31, 2012. However, client record # 1 did not include documentation of a subsequent case consultation as of April 8, 2013.
The findings were confirmed during an interview with the facility director on April 8, 2013 at approximately 3:00 P.M.
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Plan of Correction
The Facility Director/Clinical Supervisor will provide training to counselor to ensure that case consultation notes are completed quarterly on clients that are in treatment for one year or less. The training will be conducted on or before 5/31/13. The Facility Director/Clinical Supervisor will ensure compliance by monitoring during weekly supervision with counselor and monthly client chart reviews. |