INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2 through 3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Teen Challenge Training Center 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 March 9, 2009.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of employee records, the facility failed to ensure that the clinical supervisor went to the core curriculum training within six months of promotion to the clinical supervisor position.
The findings include:
Seven employee records were reviewed on February 3, 2009. One clinical supervisor was required to go to a core curriculum in clinical supervision training. The facility did not ensure that the clinical supervisor, employee # 3, attended the training.
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Plan of Correction
Clinical Supervisor has been in contact with the Bureau of Drug and Alcohol Programs and was assured that as soon as the next Clinical Supervision Training is scheduled they will notify him by phone. When the
call comes in the clinical Supervisor will sign up regardless of where it is held in the State. The Clinical Supervisor will call every 2 weeks until the course is scheduled. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of employee records, the facility failed to document training in the use of fire extinguisher for new employees.
The findings include:
Seven employee records were reviewed on February 3, 2009. Two new employees required fire extinguisher training within seven days. The facility did not provide fire extinguisher training for one of two new employees within seven days of employment, employee # 5 did not receive the training until six weeks into his employment.
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Plan of Correction
The Human Resource Director will notify the Director of Development of any new hire before or on the start date of any new employee to insure all future staff be trained within the first week. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to properly document progress notes in six of seven client records.
The findings include:
Twelve client records were reviewed on February 4 through 5, 2009. Progress notes were required in seven client records. Clinicians within the facility copied and pasted the plan portion of the progress notes in client records # 1, 2, 4, 5, 6 and 7.
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Plan of Correction
The Clinical Supervisor met with the counselor's and instructed them to be thorough in writing out the plans in the D.A.P. notes. Counselors were instructed to put more information down in the PLAN portion of the note and not just a statement of them meeting next week. Details of the next session plan should be written out and what specific preparations will the student need to accomplish before the next 1-on-1. The Clinical Supervisor will review the D.A.P. notes of the counselor's when he review a monthly random file from each counselor. |
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 the review of client records, the facility failed to fully document discharge summaries five of six client records.
The findings include:
Fourteen client records were reviewed on February 4 though 5, 2009. Discharge summaries were required in six of fourteen client records. The facility did not document the reason for this particular treatment episode in five of six client records, # 7, 9, 10, 11 and 12.
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Plan of Correction
The Clinical Supervisor met with the counselor's and instructed them to include another purpose of the student on why he entered treatment in addition to his drug addiction and use. Examples where discussed amongst the counselors and the Supervisor pulled a random file of an unknown student and reviewed the information in the Psychosocial and each counselor was asked to write down a reason for treatment. They were handed in and read out loud and discussed. The Clinical Supervisor will review the Discharge Summery of the counselor's when he reviews a monthly random file from each counselor. |