INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6, 2008 through May 7, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Child Guidance Resource Centers, Inc. 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 and a plan of correction is due on June 9, 2008.
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Plan of Correction
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document a work performance evaluation in one of three personnel records reviewed, #3.
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Plan of Correction
A performance evaluation was completed for employee #3 on 6/2/08. In accordance with HR Policy #202, in collaboration with the D&A Facility Director, the Clinical Manager of Outpatient Services will conduct an annual performance evaluation to communicate how well the employee is performing assigned D&A clinical responsibilities. The steps that CGRC will take to ensure that this deficiency does not recur is as follows: Work with Human Resources department to develop tickler/reminder system as yearly performance evaluations become due. In addition, the D&A Facility Mabager will work with Human Resources to ensure all D&A evaluations are completely annually. |
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 and staff interview, the facility failed to document a treatment plan update in one of one client record reviewed, #1. The treatment plan update did not include an assessment of the client's progress in relation to the prior treatment plan goals.
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Plan of Correction
In accordance with Clinical Policy #710, Procedures #710.01, 710.02, Drug & alcohol clincial staff will be re-trained on the following:treatment plan timeframes,update and follow-up on previous treatment plan goals, assessment and progress. These treatment plans will also require clinical supervisor sign off. Monitoring to ensure compliance is conducted by clinical supervisor during individual supervision with D&A counselor, Medical Records Manager through monthly chart audits and Peer Review Committee at monthly chart review meetings. Re-training will be provided through weekly individual supervision with the clinical supervisor,monthly staff inservices, and clinical leadership trainings.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and staff interview, the facility failed to document an aftercare plan including future goals with time frames in one of one client record reviewed, #3. The aftercare plan included general goals which were not measurable and time frames were missing.
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Plan of Correction
In accordance with Clinical Procedure #670.03, our Drug & Alcohol After Care Plan was revised. The revision of this form was completed by Medical Record Manager and the clinical supervisor will be responsible to monitor appropriate measurable goals and time frames during supervision with D&A therapist/counselor.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and staff interview, the facility failed to document a discharge summary in one of one client record reviewed, #3. The document the facility used as a discharge summary was missing the reason for treatment, services offered, the client's response to treatment and the client's status upon discharge.
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Plan of Correction
In accordance with Clinical Procedure #660.01, the Drug & Alcohol will utilize the revised agency Discharge Summary/Continuing Care Plan form. Medical Record Manager and Facility Director have discontinued the use of the D&A Discharge Instructions Form and have made revisions to the agency Discharge Summary form. This discharge summary includes questions and prompts that meet all licensing requirements. Medical Record Manager and Facility Director have trained the D&A staff on the implementation and utilization of the revised form. The clinical supervisor will be responsible for monitoring through review of content of this form with D&A therapist/counselor prior to discharge. In addition,the clinical content on the discharge form is reviewed quantitively and aggregated on a monthly basis at Peer Review Committee meetings. It is also submitted to our Quality Improvement department and presented monthly to the Utilization Management committee. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and staff interview, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training within the required time frame in one of three client records reviewed, 3.
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Plan of Correction
In accordance with 704.11 (c)(1), Mandatory Communicable Disease Training, employee #3 received 6 hours HIV training on 4/28/08 and 4 hours TB/STD training on 5/19/08. The Human Resources department/training coordinator upon hire of all D&A employees will schedule HIV/STD mandatory trainings as appropriate based on clinical and/or administration function in the D&A program. |