INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Adult & Teen Challenge 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document an annual written training plan for each employee, appropriate to that employee's skill level with input from both the employee and the supervisor. The facility's training year is from July 1, 2021 through June 30, 2022.
Employee #1 was hired as a Project Director on January 18, 2018 and was still in the position as of the date of the onsite inspection. The training plan was dated January 5, 2022.
Employee #2 was hired as a Facility Director on May 17, 2019 and was still in the position as of the date of the onsite inspection. The training plan was dated January 5, 2022.
Employee #3 was hired as a Clinical Supervisor on September 21, 2021 and was still in the position as of the date of the onsite inspection. The training plan was dated January 5, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0063: Training plan has been completed for current training year.
Policy has been changed to ensure that future training years training plan will be signed within 30 days of beginning of new training year in July and will reflect training year to be July 1 to June 30.
Future training plans will be individualized. Training plan form was edited to ensure individualization of all training plans in the future.
On March 16, 2022 Director of Counseling Services trained counselors and Clinical Supervisor on updated training requirements.
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705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical site inspection, the facility failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in the kitchen.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
P131 Thursday April 7, 2022, Director of Food Services purchased an ABC rating fire extinguisher and installed in the kitchen, in addition to the K rating fire extinguisher which was present during inspection. The Quality Assurance department will ensure proper fire extinguisher remains installed and inspected in the kitchen during quarterly walk throughs. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the June 2021 through February 2022 fire drill logs, the facility failed to document whether a fire alarm or smoke detector was operative at the time of the drill.
The finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 25, 2021 licensing inspection.
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Plan of Correction
P147 On February 13, 2022 Fire Drill Logs were updated to reflect whether a smoke detector or fire alarm was operative at the time of the drill. Training was conducted with Quality Assurance Team who facilitates fire drills, regarding fire drill procedure and documentation. Ongoing, Quality Assurance will ensure all required information is documented during each fire drill. Fire drill logs will be audited by Quality Assurance Director quarterly. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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, the facility failed to provide a complete client record, which is to include discharge summary in one out of three discharged records reviewed.
Client #14 was admitted on January 11, 2022 and was discharged on February 8, 2022.
The finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 25, 2021 licensing inspection.
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Plan of Correction
L1811: As of writing of this plan of correction, Client 14 discharge summary has been completed.
Director of Counseling Services met with Counselors on March 16, 2022 to present deficiency and provide training that discharge summaries shall be completed in accordance with DDAP regulations and internal policies.
Monthly chart audits, completed by clinical supervisor, will review random sample of discharge summaries.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of four discharged records reviewed.
Client #11 was admitted on December 4, 2021 and was discharged on January 3, 2022.
Client #12 was admitted on January 17, 2022 and was discharged on February 14, 2022.
Client #14 was admitted on January 11, 2022 and was discharged on February 8, 2022
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 25, 2021 licensing inspection.
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Plan of Correction
L1813: As of the writing of this plan of correction, Client 11, 12 and 14 follow up contacts have been completed and documented.
Director of Counseling Services met with Counselors on March 16, 2022 to present deficiency and provide training that discharge summaries shall be completed in accordance with DDAP regulations and internal policies.
Monthly chart audits, completed by clinical supervisor, will review random sample of follow up contacts.
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