INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10, 2014 and April 14, 2014 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.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of six record reviewed.
Findings:
Six personnel records were reviewed on February 11, 2014. In personnel record #3, the counselor did not meet the qualifications for the position of counselor based on a Bachelor Degree in World Ministries. In addition, a review of the employee's application he also didn't meet because he didn't have the required one year clinical experience.
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Plan of Correction
Employee #3's drug and alcohol case load has been reassigned to two full counselors on 4/1/2014. The counselor was suspended as of 4/1/2014 for an unrelated matter and will not return to counselor status. Program Director will ensure that all assistant counselors meet the Department of Health requirements for counseling before making them a full counselor hereafter to assure compliance according to the standard of Promotion of an Assistant counselor. The Student Service Director will be responsible to ensure corrective action is implemented. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor assistant met the qualifications for a counselor position before being promoted in one of six records reviewed.
Findings:
Six personnel records were reviewed on February 11, 2014. In personnel record #3, the counselor did not meet the qualifications for the position of counselor based on a Bachelor Degree in World Ministries. Employee #3 was hired on October 1, 2012 as a counselor assistant and promoted on June 21, 2013. Employee #3 does not have the required degree or 1-year clinical experience.
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Plan of Correction
Employee #3's drug and alcohol case load has been reassigned to two full counselors on 4/1/2014. The counselor was suspended as of 4/1/2014 for an unrelated matter and will not return to counselor status. Program Director will ensure that all assistant counselors meet the Department of Health requirements for counseling before making them a full counselor hereafter to assure compliance according to the standard of Promotion of an Assistant counselor. The Student Service Director will be responsible to ensure corrective action is implemented. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that the grounds of the facility were clean and in good repair.
Findings:
A physical plant inspection was conducted on 4/14/2014. A Department Licensing Specialist observed that multiple areas and rooms throughout the facility had stained ceiling tiles, dirty walls and floor, walls and floors in disrepair, and equipment in disrepair. The following deficiencies were found:
were numerous ceiling tiles throughout the facility that were stained and in disrepair. There were stained and damaged ceiling tiles in hallways, 1st floor bathroom, kitchen area, dry food storage area of the Administration Building; in the main ceiling, bathroom, shower room, exercise equipment room, side storage room, front storage room of the gymnasium; in the hallways, recreation room, storage closet and the reading room of the residential building.
dryer vent hose for the dryer located in the dry food storage area in the administration building was not securely connected to the designated ventilation and lint collection bucket. Additionally, the lint collection system was not a UL approved system.
was evidence of mold on three of the ceiling tiles in the dry food storage area in the administration building and two of the ceiling tiles in the shower room in the gymnasium.
were five pieces of exercise equipment that had torn and taped padding in the gymnasium.
were sections of tile that were missing on three different sections of the shower room wall in the gymnasium.
were four sections of the shower floor in the gymnasium that were not clean and had brown stains. Each stain was approximately 3 " by 3 " . Additionally, there were multiple sections of the shower wall that had brown stain streaks and markings.
window blinds in Bedroom 7 - 25 were in disrepair as the blinds were removed from the brackets that were in place. The facility was utilizing bed linens that were nailed to the window frame and draped over the windows in lieu of functional blinds.
were metal desks in bedrooms 14, 19, 20 and 24 that were each missing at least two drawers. Additionally, the drawers that were present for the desks in Bedroom 14 and 19 were in disrepair as they were bent and misshaped.
were dressers for clothing storage in in bedrooms 17 and 24 that were missing drawers. The dresser in Bedroom 17 was missing the top two small drawers. The dresser in Bedroom 24 was missing the second large drawer from the bottom.
intercom speaker units located on the ceiling in Bedrooms 15 and 24 were in disrepair. The covers were bent and misshaped, which exposed the inner wiring and components of the unit.
was a standard square floor fan that was secured to the open end of the top bunk bed closest to the door in Bedroom 9. The fan was secured to the bed with a piece of rope just above the secured ladder. This obstacle presented a hazard as it was blocking the route onto the top buck bed.
was insufficient lighting in Bedroom 18 due to one of the elongated florescent light bulbs that was not operable.
two windows in the hallway between Bedroom 9 and Bedroom 24 had large cracks that spanned across the entire sections of glass on both windows.
were two sections of the tile floor in the barber room that were cracked through the entire length of the room.
air-conditioning unit in the library was missing the plastic cover.
were four sections of carpeting that was torn and duct taped in the classroom located in the rear section of the residential building that was the furthest from the exit door.
were exposed wires from the light source that was dangling from the ceiling in the donation storage closet in the residential building. The light source did not have a cover.
aluminum frame of the window screen for the window in the computer room was bent and duct taped.
air vent in donation storage closet was caked with black dust.
The facility liaison confirmed the findings.
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Plan of Correction
Facility Director sent maintenance Personal to fix or repair the following:
1. Replaced all water stained, damaged and moldy and missing ceiling tiles throughout the whole facility which included the kitchen, food storage areas, bathrooms, Gym shower area, all hallways in academic, restrooms, offices and classrooms by 4/30/2014 .
2. Dryer vent was attached to a UL approved system by 5/6/2014.
3. Exercise equipment which was torn and taped were removed. The equipment which could be repaired was outsourced for repairs on 4/21/2014.
4. Shower Room tiles on wall were replaced or repaired by 4/21/2014.
5. Curtain rods were installed on 4/21/2014. Curtains ordered and will be installed by May 29, 2014. Temporary coverings are in place until then
6. Intercom speaker were repaired on 4/21/2014.
7. Lights were replaced in room 18 on 4/21/2014.
8. Broken window glass was removed new windows were installed on 5/7/2014.
9. Barber room cracked floor was sealed on 4/21/2014.
10. Air Conditioner unit in Library was covered on 4/21/2014
11. Carpet in classroom 205 was removed and floor was painted by 4/28/2014.
12. Light with exposed wire in Brother helping Brothers closet was repaired on 4/22/2014.
13. Screen from reading room was removed on 4/15/2015.
Training Manager sent custodial personal to address the following issues by:
1. Gym shower floor and walls were cleaned thoroughly on 4/16/2014. Added to the S.O.P. twice monthly which include intake week, the shower walls and floor are to be scrubbed. The Custodian will inspect each time to ensure compliance.
2. Air vent in Brother helping brothers closet was cleaned 4/22/2014. Program assistant is to ensure that custodial department has it cleaned monthly or more often if needed.
Intake director sent custodial personal to address the following issues by
1. Damaged metal desks and desks with missing drawers were removed before 4/16/2014.
2. Dressers with missing drawers were replaced by 4/16/2014.
3. Fan removed and announcement was made to student body that nothing is to hang from bed on 4 15/2014. Announcement was made to student body concerning hanging item from bed is not allowed.
To ensure that the above deficiencies do not repeat the following was communicated to:
1. Staff
A system has been established for staff who sees an issue meaning anything that needs cleaned, fixed, repaired, and unlocked will fill out a maintenance request on the computer ASAP. All requests will be reviewed daily Monday ? Friday and assigned to maintenance worker. Maintenance Director will assign a staff member to inspect work to assure completion and done properly
2. Front desk staff.
A system has been established for front desk staff who see any issue meaning anything that needs cleaned, fixed, repaired, and unlocked. They will write down the issue along with their name on the Evening/Weekend Duty Shift Report. The Program Assistant will fill out a maintenance request on the computer the next day or on Monday in case of a weekend shift. All requests will be reviewed daily Monday ? Friday and assigned to maintenance worker. Maintenance Director will assign a staff member to inspect work to assure completion and done properly.
3. Students
A system has been established for students who sees any issue meaning anything that needs cleaned, fixed, repaired, and unlocked that needs addressed that they go to the counselor, Student Services Manager or Program Assistant during the day and report it. The staff to which is has been reported to must then fill out a maintenance request on the computer. In the evening or weekend the student will go to the front desk. The front desk will write down the issue along with the student's name, date and time on the Evening/weekend duty shift report. The Program Manager will fill out a maintenance request on the computer the next day or on Monday in case of a weekend shift. All requests will be reviewed daily Monday ? Friday and assigned to maintenance worker. Maintenance Director will assign a staff member to inspect work to assure completion and done properly. A Memo was posted in the lounge to remind student of the procedure.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that all trash was stored in covered receptacles.
Findings:
A physical plant inspection was conducted on 4/14/2014. A Department licensing specialist observed 12 large trash bags lying on the ground outside of the food drop off area of the administration building.
The facility liaison confirmed the findings.
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Plan of Correction
The twelve Bags of trash were removed within the hour of the infraction by the coustidial Department. Hereafter, all trash is directly taken to a truck or trailer then taken to the dumpster twice daily by the custodial crew. This Policy was added to the S. O. P of the custodial department. The "Custodian" will assure that Policy is strictly adhered to by checking daily that the trash is removed properly. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure privacy during a group counseling session.
Findings:
A group counseling session was in process on 4/14/2014 as Department Licensing Specialists were conducting a physical plant inspection of the counseling offices in the residential building. The vision panel in the door to the counseling room lacked proper window treatments to ensure privacy. Clients could be observed from the waiting area outside of the office.
The facility liaison confirmed the findings.
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Plan of Correction
On April 17, 2014 liaison to the state addressed the counseling Department concerning covering the window during counseling and or group sessions of all Drug and Alcohol students. The Lead Counselor shall ensure compliance by random checks. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that all client mattresses were in good repair.
Findings:
A physical plant inspection was conducted on 4/14/2014. The uncovered bed mattresses that were not currently being used by clients in Bedrooms 14, 15 and 16 were in disrepair as they each had multiple tears on the top section of the mattresses.
The facility liaison confirmed the findings.
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Plan of Correction
We used mattresses of empty bed in non-drug & alcohol rooms to replace the drug and alcohol mattresses that were ripped or torn. We ordered 17 new mattresses to be placed on the empty beds in the non-drug and alcohol rooms which include 5 extra mattress to be available for future replacement. To ensure that mattress which need replaced are done so right away in the future the "Front Desk Staff shall inspect each mattress each week during Saturday morning (GI) General Inspection. They will then notify "Intake" of those mattresses that need replaced and "Intake" will be responsible to replace mattress. "Intake" will also notify the "Director of Finance" when more mattresses need to be ordered. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on an observation during the physical plant inspection, the facility failed to provide paper towels or a mechanical dryer in each bathroom.
Findings:
A physical plant inspection was conducted on 4/14/2014. The facility failed to provide paper towels or a mechanical hand dryer in the L-wing bathroom in the residential building.
The facility liaison confirmed the findings.
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Plan of Correction
Hand towels have been placed in the restroom and those that do not have air dryers on 4/15/2014. To ensure that this does not repeat custodial will restock daily Monday through Friday, Kitchen Personal will keep stock up over the weekends. The Chef will check periodically to ensure compliance. Teen Challenge has ordered Air Dryers to be placed in all restrooms. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that the hot water temperature was maintained at or below 120 degrees Fahrenheit.
Findings:
A physical plant inspection was conducted on 4/14/2014. The following hot water temperatures were recorded at the following locations:
Administrative Building:
degrees Fahrenheit at the kitchen bathroom sink
degrees Fahrenheit at the 1st floor men ' s bathroom sink
degrees Fahrenheit at the 2nd floor men ' s bathroom sink
degrees Fahrenheit at the 2nd floor ladies bathroom
Gymnasium Building:
degrees Fahrenheit at the men ' s bathroom sink
The facility liaison confirmed the findings.
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Plan of Correction
Maintenance Director adjusted the water temperature at the water heaters. In the gym and Wilkerson Hall. In order to prevent this from reoccurring the Maintenance Director placed a sign on the water heaters indicating the proper setting of the water heater. He shall randomly inspect to ensure compliance. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that all of the bathrooms were ventilated by an exhaust fan or window.
Findings:
A physical plant inspection was conducted on 4/14/2014. The L-wing bathroom located in the immediate vicinity of the recreation room in the residential building did not have a source of ventilation.
The facility liaison confirmed the findings.
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Plan of Correction
An air vent was ordered and will be installed by the maintenance department by 5/23/2014. In order to ensure that this does not reoccur the Maintenance Director will be responsible to ensure all rest rooms have an air vent hereafter. The Maintenance Director will have the maintenance department check monthly to ensure that is operating properly. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that toilet paper was provided at each toilet.
Findings:
A physical plant inspection was conducted on 4/14/2014. The facility failed to provide toilet paper within the following bathrooms:
toilet paper dispenser in the second stall in the 2nd floor men's bathroom in the administrative building
of the bathrooms located in the residential building
The facility liaison confirmed that there was no toilet paper in the bathrooms.
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Plan of Correction
Bathroom tissue has been provided at all times at each toilet. Maintenance Department will have replaced and installed a total of 27 toilet paper holders by June 2, 2014. To ensure that this doesn't repeat the Custodial Department will check daily that toilet paper is supplied. The Custodian will assure this is done. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on an observation during the physical plant inspection, the facility failed to maintain all of the bathrooms in a sanitary manner.
Findings:
A physical plant inspection was conducted on 4/14/2014. A strong odor of urine was identified upon entering the men's bathroom by Bedroom 25. There were yellow stains and wet puddles of urine on the tile floor directly under both of the urinals in the bathroom.
The facility liaison confirmed the findings.
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Plan of Correction
Training Manager sent custodial to scrub floor and walls with deodorizer, bleach and all-purpose cleaner on 4/15/2014. To ensure this doesn't happen again the custodial department will scrub daily. The "Custodian" will daily inspect the bathrooms that they are scrubbed. |
705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that all food preparation areas were clean.
Findings:
A physical plant inspection was conducted on 4/14/2014. The following food preparation areas were not clean:
were particles of cereal on the floor in the middle and corner of the dry food storage area in the administrative building.
were black grease stains and three french fries on the gymnasium kitchen floor by the deep fryer.
The facility liaison confirmed the findings.
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Plan of Correction
Both the Food Storage Area and the Kitchen in the Gym were cleaned thoroughly on 4/14/2014. The Storage room will be swept and cleaned daily by kitchen personal and the kitchen in the Gym will be cleaned by kitchen personal after every use. To ensure compliance daily inspections will be done by the "Chef" in storage room and gym kitchen when it is used. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that all egress routes were unobstructed.
Findings:
A physical plant inspection was conducted on 4/14/2014. The push bar doors that exit out the side of the gymnasium were locked with a small lift and turn dead bolt mechanism that was located at the top of the door. This obstruction prevents the immediate egress from the facility. Additionally, the push bar doors that exit out the rear of the gymnasium were equipped with the same lift and turn dead bolt mechanism.
The facility liaison confirmed the findings.
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Plan of Correction
After conversing with Licensing Specialist on 5/5/2014 he agreed that there were no push door but a door knob. However the dead bolts were removed from the East (rear, as identified by Licensing Specialist) and West doors with knobs. To ensure this doesn't happen again Maintenance Director will research code and install properly security devices. Maintenance director will instruct staff not to install dead bolts on top or bottom of exit doors. Front Desk will check Gym daily minimally weekly whenever the gym is used to assure ant obstructions are removed and reported on the Evening/Weekend Duty Shift Report. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that all exits are clearly indicated with the use of signage.
Findings:
A physical plant inspection was conducted on 4/14/2014. There was no exit sign above the exit doors with panic hardware that exit out the side of the gymnasium.
The facility liaison confirmed the findings.
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Plan of Correction
After conversing with Licensing Specialist on 5/5/2014 he agreed that there were no panic hardware but a door knob. However a sign was placed on South entrance which states from the inside "Not An Exit" and outside which state "Use Other Entrance" To ensure this does not reoccur custodial staff shall report if sign is removed. Maintenance Director will have staff check signage by door semi-annually to insure proper identification of all exits. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on an observation during the physical plant inspection, the facility failed to light interior stairs and exits at all times.
Findings:
A physical plant inspection was conducted on 4/14/2014. The clinical counseling offices were inspected as part of the physical plant inspection. The light source in the rear stair tower from the 2nd floor counselor office was not operable.
The facility liaison confirmed the findings.
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Plan of Correction
Light was fixed on 4/14/2014. In order to insure this doesn't repeat the counselor who uses the stairway is to fill out a work order through manage engine on the computer. Also Maintenance Department will do monthly check of lights to ensure working. The Director of Maintenance will ensure this is done |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that all fire extinguishers were mounted and placed in the designated locations.
Findings:
A physical plant inspection was conducted on 4/14/2014. The wall by the rear exit in the gymnasium had a sign with a red arrow that read " Fire Extinguisher " that pointed down to a metal mounting hook. A fire extinguisher was not mounted at that designated location.
The facility liaison confirmed the findings.
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Plan of Correction
The missing fire extinguisher was replaced on 4/18/2014 and inspected by S.A. Comunale on 4/21/2014. The ensure that this doesn't happen the Maintenance Supervisor will have Maintenance check all fire extinguishers monthly The Facility Director shall replace any missing extinguisher with extra in stock. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that all of the fire extinguishers were inspected and approved annually.
Findings:
A physical plant inspection was conducted on 4/14/2014. All of the fire extinguishers throughout the residential building, gymnasium, and administration building were inspected and approved in March 2013 with the exception of one fire extinguisher that was resting on the floor in the gymnasium kitchen that was inspected and approved in May 2011. All of the fire extinguishers had not been re-inspected as of the date of this inspection.
The facility liaison confirmed the findings.
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Plan of Correction
Fire Extinguisher were Inspected by S.A. Comunale on 4/21/2014. Extra extinguishers were used to replace those that needed tested or recharged. To ensure that this doesn't happen the Maintenance Supervisor will have maintenance check all fire extinguishers monthly. The Facility Director shall replace any missing extinguisher with extra in stock. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to have a complete record in four of eleven records reviewed.
The findings include:
Eleven client records were reviewed on February 10, 2014. Five of the eleven client records were reviewed for follow-up information, #7, 8, 9, 10 and 11. Client records #7, 8 and 9 had follow-ups documented but it was an identical follow-up documentation except for the name of the client. Client record # 10 failed to show documentation that a follow-up was done.
Client # 10 was discharged on July 26, 2013. As of the date of the licensing inspection, there was no documentation of a follow-up.
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Plan of Correction
The Liaison had set up a training on May 1, 2014 where all counselors and assistant counselors retrained on the proper way to complete follow-up contact reports. There was a follow-up contact Report completed, however the counselor placed the wrong date on the Graduation Date of the form. Counselor was to put the graduation date for the Drug and Alcohol part of the program but he put the future completion date of the whole discipleship program down. Counselor crossed out the wrong date and placed 7/26/2013 the right date of Drug and Alcohol Completion. The form was changed to ask for completion of Drug and Alcohol instead of Graduation date to avoid confusion in the future. Lead Counselor will randomly will pull 1 file from each counselor and assistant counselor each month to insure documentation is complete and properly done. This shall be done on a monthly Basis. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on an observation during the physical plant inspection, the facility failed to follow their policy regarding the storage of food items.
Findings:
The facility ' s policy regarding the storing of food included the following language: " All food, while being stored, prepared, or served, or during transportation, will be protected from contamination ... "
A physical plant inspection was conducted on 4/14/2014. The facility failed to ensure that all of the food items in the freezers and walk-in refrigerators were covered and protected from contamination. The following items in the administration building kitchen were not covered:
trays of frozen hamburger patties and a tray of sausage links on a tray stacking cart that were not covered in freezer #1.
trays of sausage links and a tray of burritos on a tray stacking cart that were not covered in freezer #2.
bin that was half-full with pieces of frozen French toast that was not fully covered as there was a large tear in the saran wrap.
bin full of sausage links in the walk-in refrigerator that was not covered.
The facility liaison confirmed the findings.
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Plan of Correction
The trays of food were covered within minutes of the discovery by kitchen staff on 4/14/2014. Uncovered bin was reboxed, wrapped and dated within minutes of the discovery by kitchen staff on 4/14/2014. In order to ensure future compliance the Chef will instruct staff and student concerning the covering all food while in storage. Chef will assure compliance hereafter by checking that all food in storage is covered daily when working. |