INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2022, 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on March 18, 2022, the facility failed ensure that there was proper ventilation by either an exhaust fan or a window in either of the two bathrooms available to clients.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facilities Manager will ensure functional bathroom exhaust fans are installed by 6/30/2022. The Facilities Manager will ensure this does not recur by verifying functionality on the monthly building walk through. Results of the walk through will be reported to the Environment of Care Committee and minutes from this meeting will be sent to Operations monthly. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs between January 2021 and January 2022, the facility failed to ensure that fire drill logs included the exit route used for fire drills conducted in the 2021 months of December, November, October, September, July, June, March, February, and January. Additionally, the fire drill log for December 2021 did not include the number of persons in the facility at the time of the drill.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facilities Manager will review the forms monthly and verify that all fields including evacuation routes used and number of staff participating are recorded. If in any instance evacuation information is incomplete, the drill will be redone. All drills will be reviewed monthly at the Environment of Care Committee. This committee will report on the status of compliance with drill requirements and other fire safety standards to the Operations group on a monthly basis. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection on March 18, 2022, the facility failed to maintain protective caps over each electrical outlet.
The bathroom located in the lobby did not have a protective cap over one electrical outlet.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facilities Manager will ensure protective caps are in place for all exposed outlets in client facing areas by 3/31/2022. Monthly checks will be conducted to ensure the outlets remain protected. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of two client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in one record reviewed.
Client #2 was admitted on February 14, 2020 and was discharged on May 11, 2021. There was an informed and voluntary consent form to the funding source, signed and dated by the client on February 18, 2020, which expired on February 17, 2021. There was documentation of billing after the expiration date and there was no updated consent form signed by the client documented in the record prior to the disclosures.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will review the annual update process with the clinician in individual supervision. An automated reminder system was implemented in February 2022 in which clinicians receive weekly emails alerting them to any documentation that is due for an annual update. |
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 two client records, the facility failed to follow their policy to complete case consultations every 90 days in one client record reviewed.
Client #2 was admitted on February 14, 2020 and was discharged on May 11, 2021.The client record contained a case consultation note on May 18, 2020 and the next one was due on August 18, 2020; however, it was not completed until September 18, 2020. The next case consultation was due to be completed by December 18, 2020; however, the record did not contain documentation that another case consultation was completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will review the required 90 day time frame for completion of Case Consultation notes with the clinician in individual supervision. Completion will be documented in individual supervision notes by the Facility Director. The Facility Director in collaboration with the Medical Records Department will monitor compliance through chart review on an ongoing basis. The Facility Director will ensure the corrective action is implemented and will monitor the plan of correction. |