INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility ' s policy and procedures manual related to a staff development program, the facility failed to ensure that the policy for the following components indicated who is responsible and the timeframes for completion: an assessment of staff training needs, an overall plan for addressing these needs, a mechanism to collect feedback on completed training, and an annual evaluation of the overall training plan.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
An assessment of staff training needs will be completed by the end of the calendar year by the Project Director, Senior Director of Juvenile Support and Prevention Services at Child Guidance Resource Centers. Feedback will be collected via a survey and used to evaluate the overall training plan within 30 days of the end of the year. Updated training plans will be implemented by the first of the year by the Project Director, Senior Director of Juvenile Support and Prevention Services at Child Guidance Resource Centers. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to include within their unusual incident policy, a specific policy and procedures that addresses how the facility would respond to the selling or use of illicit drugs on the premises.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The incident management policy was updated by CGRC's Vice President of Performance Improvement to include the following:
Selling or using illicit drugs on the premises. Any instance where a staff observes this activity is reported immediately to the supervisor who will consult with staff about contacting law enforcement.
If there is immediate risk to the safety of the individual or others, police will be contacted, and the medical emergency procedure will be followed. If appropriate, staff will also follow the Opioid Overdose procedure and administer Naloxone.
CGRC shall file a written unusual incident report with the DDAP (Department of Drug and Alcohol Programs) within 3 business days following an unusual incident.
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