INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7-8, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania 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 and a plan of correction is due on April 4, 2011.
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Plan of Correction
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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 the facility summary report, and a discussion with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for five of fifteen volunteers.
The findings include:
The facility summary report was reviewed on March 7 and 8, 2011. Per regulation "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 and all other staff shall complete the training within the first 2 years of employment." Volunteers # 2,3,5,7 and 8 do not have documentation of the training and have volunteered at the facility for over two years.
A review of the facility summary report and a discussion with the facility director confirmed that the facility was unable to provide documentation that five of the facility's volunteers had had HIV/AIDS training or STD/TB training.
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Plan of Correction
Project director has informed all of our volunteers that they need HIV/AIDS and TB/STD training within the next 3 months in order to continue as volunteers. I have contacted the Allegheny Health department to do the trainings by 6-30-11. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the completion of 12 clock hours of annual training required for facility directors in one of one personnel records.
The findings include:
Five personnel records were reviewed on March 7, 2011. One personnel record pertained to the facility director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 2.
Employee # 2 has been the facility director since October 1985. The facility training year is from January 2010 through December 2010. Employee # 2 had documentation of seven hours of training for the 2010 training year. There was no other documentation of completed training for the training year ending in December 2010.
A discussion with the facility director took place on March 8, 2011 at which time it was confirmed that the facility director completed 7 hours of training for training year 2010.
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Plan of Correction
The facility director will get a minimum of 12 clock hours of annual training within the year. He has 12 hours as of the day of this correction plan 4-7-11. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in 1 of 6 clients records reviewed.
The findings included:
Eight client records were reviewed on March 7-8, 2011. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Six client records required an informed and voluntary consent from the client. The facility failed to obtain an informed an voluntary consent for the disclosure of client information regarding a follow-up contact in client record #3 .
Client # 3 was admitted on June 7, 2010 and discharged on September 7, 2010. A follow-up call was made to check on the status of the client but there was not a signed release in the client file for this specific person to be called for follow-up.
A discussion with the facility director on March 8, 2011 confirmed that a release of information for this specific follow-up contact had not been signed by the client.
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Plan of Correction
Project director met with counselors and assistant counselor to discuss this deficiency. Counselors were reminded that in doing follow-up,a client must sign a voluntary consent for the disclosure of information if the client is not the one with whom the counselor is speaking to personally when follow-up is done.The date for correction of this deficiency is 4-7-11. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records and a discussion with the facility director, the facility failed to document case consultations in two of three client records.
The findings include:
Eight client records were reviewed on March 7-8, 2011. Three client records were reviewed for case consultations. Two of the three client records reviewed required case consultations.
Client # 3 was admitted on June 7, 2010 and discharged on September 9, 2010. The client was readmitted on October 8, 2010 and discharged on December 30, 2010. No documentation of a case consultation was found in the client record.
Client # 4 was admitted on October 6, 2010 and discharged on December 11, 2010. No documentation of a case consultation was found in the client record.
A discussion with the facility director on March 8, 2011 confirmed that there were no documented case consultations in the client records.
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Plan of Correction
Project director met with counselors and assistant counselor on 7/14/2011. We discussed how we have been doing case consults after three months believing that was acceptable. As of 4-30-11 we will do case consults every 2 months to be in compliance and do a case consult prior to 2 months for clients who leave treatment prematurely or are discharged prior to 2 months in treatment. |