INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15-16, 2017, by staff from the Division of Drug and Alcohol 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility records submitted as part of the presubmission process, and based on interviews conducted with staff during the onsite inspection, the facility failed to ensure that the staff of the facility met the general training requirements.
The facility had no documentation current or expired of certification in first aid for any of its staff.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
A compliment of applicable drug and alcohol staff received First Aid training on September 15, 2017 and the documentation of the completed training was uploaded into their employee training files. The remaining applicable staff will be trained on October 25, 2017 from 8:00 to 10:00 am in First Aid training at the Clearfield office location. The Assistant Outpatient Director will ensure all applicable remaining staff attend the First Aid training on October 25, 2017. At the time of completion of training, documentation of First Aid training will be uploaded to employee training records. All required staff will be fully trained in CPR and First Aid by October 25, 2017.
The Center strategically trains all clinical and applicable administrative/reception staff at each licensed location to ensure adequate coverage at all times and during staff transitions. Routine assessment will be conducted by the Assistant Director at times of staff transition to determine the need to secure additional training for new staff. Once a need is identified training will be secured and applicable new staff will be trained to ensure full compliance with regulatory requirements. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted as part of the onsite inspection, the facility failed to properly maintain the water temperature in its bathrooms.
The hot water temperature for the clients' restroom was tested at 140 degrees Fahrenheit.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Upon identification of water temperature in excess of 120 degrees the Center immediately reduced the heat settings on the hot water tank to ensure compliance. Subsequent weekly monitoring of the water temperature have not yielded readings in excess of 120 degrees. The Center's maintenance man will continue to routinely monitor water temperatures, bring any readings over 120 degrees to the attention of the Facility Director, and immediately make adjustments if warranted due to water temperature reflecting readings in excess of 120 degrees Fahrenheit. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of facility records submitted as part of the presubmission process, and based on interviews with facility staff, the facility failed to follow the required procedures in performing its fire drills.
From July 29, 2016, through the time of the onsite inspection, the facility only evacuated through the rear exit for all of it fire drills.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Based on licensing feedback, the Center has retrained designated members of the Center Safety Committee that are responsible for executing monthly unannounced fire drills. Beginning in September 2017, the Center has implemented protocol that monthly unannounced fire drills will utilize alternative exit routes throughout the licensing year and will accurately document which exits were utilized during the execution of the fire drill. Oversight to ensure this will be completed by the OP Assistant Director monthly. |
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 facility outpatient records conducted as part of the onsite inspection, the facility failed to update client treatment plans at least once every 60 days in 3 of 7 records reviewed.
Client #4 was admitted for treatment on 08/04/2016, and discharged on 11/08/2016. The client had a treatment plan update dated 11/08/2016, but the next treatment plan update was not completed until 02/08/2017.
Client #5 was admitted for treatment on 08/08/2016, and discharged on 07/12/2017. The client had a treatment plan update dated 10/25/2016, but the next treatment plan update was not completed until 01/03/2017.
Client #6 was admitted for treatment on 10/03/2016, and discharged on 05/18/2017. The client had a treatment plan update dated 01/08/2017, but the next treatment plan update was not completed until 05/03/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Outpatient Drug and Alcohol treatment staff were retrained during staff meeting on August 23, 2017 on the requirements for client treatment plans to be completed at a minimum of every 60 days. Applicable reporting mechanisms were reviewed to ensure staff were familiar with report track compliance related to treatment plan completion deadlines. Monthly compliance audits completed by the Outpatient and Assistant Outpatient Director will routinely monitor and document treatment plan compliance ensure treatment plans are completed within regulatory guidelines. Additionally, treatment plan reports will be reviewed at each individual supervision to ensure compliance ongoing. |