INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 17-19, 2015 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:
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facility's staff schedule work hours and the first aid and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR and first aid during the project's hours of operation.
The findings include:
The facility's staff schedule work hours and the first aid and CPR certification cards were reviewed on February 19, 2015. A review of the January 2015 work schedule failed to document CPR First Aid coverage between the hours of 5pm through 7am.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On Monday, February 10, 2015, a certified trainer came up and trained 7 staff in CPR/First aid, and these staff represent all covered hours. The certification cards were sent to DDAP office on February 12, 2015. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel files, the facility falied to document at least 25 clock hours of training for each counselor.
The findings include:
One personnel record was reviewed for the position of counselor on February 17, 2015. The facility's training year reviewed was January 1, 2014 through December 31, 2014. The facility failed to document training hours for the 2014 training year in personnel record #1.
The findings were discussed with the facility staff during the licensing process.
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Plan of Correction
Counselor failed to complete his required 25 clock hours before the December 31 deadline. An internal warning was issued for him. His clock hours for 2015 are completed.
The facility director will perform a bi-monthly review of all counselors and their training hours to make sure they are compliant. |
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, the facility failed to obtain an informed and voluntary consent from the client in one of ten client records.
The findings include:
Ten client records were reviewed on February 17-19, 2015. Ten client records were required to include an informed and voluntary consent from the client prior to the disclosure of information. The facility failed to obtain an informed and voluntary consent in record #6.
Client #6 was admitted to treatment on December 6, 2014, and was still active in treatment as of the date of the inspection. A letter address to " whom it may concern " was sent out identifying the client ' s presence in treatment.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor and director will perform a monthly file review of counselor files to ensure that the proper consents are present. This action will begin on 2/20 15 and occur monthly.
We will pull random files from each counselor and make sure that the consent forms are in order and that any communication contained in the file has a consent form associated with it. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records the facility failed to impliment a data collection and record-keeping system that allows for the efficient retrieval of data.
The findings include:
A client record review was conducted February 17-19, 2015. A list of discharged clients for the six month timeframe prior to the inspection was requested. The facility was unable to provide a list based on clients who received treatment and were discharged from drug and alcohol treatment within the specified time frame.
The findings were discussed with the facilty staff during the licensing inspection.
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Plan of Correction
Facility director will make sure that there is a database kept, which is easily accessible, which will display the information of the clients that have been discharged within the requested timeframe. This action will be completed on 2/20/15. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to provide treatment plan updates every 30 days in four of eight client records.
The findings include:
Ten client records were reviewed on February 17-19, 2015. Treatment plan updates were required in eight client records. Treatment plan updates are required every 30 days. The facility failed to document treatment plan updates in client records #4, 7, 8, and 9.
Client record #4 was admitted on October 24, 2014 and was discharged on February 10, 2015. The most recent treatment plan update was documented on December 30, 2014. A treatment plan was due no later than January 30, 2015. The treatment plan update was not documented at the time of the licensing inspection.
Client record #7 was admitted on October 3, 2014 and was discharged on January 30, 2015. The most recent treatment plan update was documented on December 17, 2014. A treatment plan was due no later than January 17, 2015. The treatment plan update was not documented at the time of the licensing inspection.
Client record #8 was admitted on August 28, 2014 and was discharged on January 2, 2015. The most recent treatment plan update was documented on November 12, 2014. A treatment plan was due no later than December 12, 2014. The treatment plan update was not documented at the time of the licensing inspection.
Client record #9 was admitted on October 1, 2014 and was discharged on January 30, 2015. The most recent treatment plan update was documented on December 15, 2014. A treatment plan was due no later than January 15, 2015. The treatment plan update was not documented at the time of the licensing inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Counselor and Facility Director, will check all files on a monthly basis to ensure that treatment plan updates are being filed every 30 days as regulations require. This action will commence on 2/20/15 and occur monthly. |
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 the review of client records, the facility failed to provide a complete client record on each individual in ten of ten client records.
The findings include:
Ten client records were reviewed on February 17-19, 2015. Ten client records were reviewed from the inpatient non-hospital - residential treatment activity, and a complete client records were required. The facility failed to provide a complete client record in all records reviewed, #1-10.
Client #1 was admitted to treatment on December 27, 2014 and was still active in treatment as of the date of the inspection. The facility failed to document the client's record of service as of the date of the licensing inspection. Additionally, the facility failed to document the client's physical examination as of the date of the licensing inspection.
Client #2 was admitted to treatment on November 21, 2014 and was still active in treatment as of the date of the inspection. The facility failed to document the client's record of service as of the date of the licensing inspection.
Client #3 was admitted to treatment on November 28, 2014 and was still active in treatment as of the date of the inspection. The facility failed to document the client's record of service as of the date of the licensing inspection.
Client #4 was admitted to treatment on October 24, 2014 and was still active in treatment as of the date of the inspection. The facility failed to document the client's record of service as of the date of the licensing inspection.
Client #5 was admitted to treatment on January 13, 2015 and was still active in treatment as of the date of the inspection. The facility failed to document the client's record of service as of the date of the licensing inspection.
Client #6 was admitted to treatment on December 16, 2014 and was still active in treatment as of the date of the inspection. The facility failed to document the client's record of service as of the date of the licensing inspection. Additionally, the facility failed to document the client's preliminary treatment plan, and comprehensive treatment plan as of the date of the licensing inspection.
Client #7 was admitted to treatment on October 3, 2014 and was discharged on January 30, 2015. The facility failed to document the client's record of service as of the date of the licensing inspection.
Client #8 was admitted to treatment on August 28, 2014 and was discharged on January 2, 2015. The facility failed to document the client's record of service as of the date of the licensing inspection.
Client #9 was admitted to treatment on October 1, 2014 and was discharged on January 30, 2015. The facility failed to document the client's record of service as of the date of the licensing inspection.
Client #10 was admitted to treatment on July 16, 2014 and was discharged on November 28, 2014. The facility failed to document the client's record of service as of the date of the licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselor and Facility Director, will perform a monthly review of all counselor files to ensure that the record of services, physical exam form and preliminary treatment plans are in each client record. This action will commence on 2/20/15 and occur on a monthly basis. |