INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 3-5, 2016 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:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to document the required close supervision and direct observation for counselor assistants in four of four personnel records of counselor assistants reviewed.
The findings include:
Four personnel records of counselor assistants requiring documentation of close supervision were reviewed during the renewal inspection on February 3-5, 2016. The facility failed to clearly demonstrate in weekly supervision notes that required close supervision of counselor assistants was occurring in personnel records # 5, 6, 7, and 8. A documented discussion of required direct observation was not included in corresponding supervisory notes for all four personnel records for counselor assistants.
Employee # 5 was hired on 6/1/2015 as a counselor assistant. The facility failed to include a documented discussion of required direct observation in corresponding supervisory notes, as part of the weekly close supervision from 6/4/15 - 1/14/16.
Employee # 6 was hired on 8/11/2014 as a counselor assistant. The facility failed to include a documented discussion of required direct observation in corresponding supervisory notes, as part of the weekly close supervision from 3/19/15 - 10/8/15.
Employee # 7 was hired on 2/1/2015 as a counselor assistant. The facility failed to include a documented discussion of required direct observation in corresponding supervisory notes, as part of the weekly close supervision from 2/5/15 - 10/8/15.
Employee # 8 was hired on 2/11/13 and started in the counselor assistant position on 9/1/14. The facility failed to include a documented discussion of required direct observation in corresponding supervisory notes, as part of the weekly close supervision from 2/5/15 - 10/8/15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Letters were completed for all counselor assistants whose level of supervision was promoted.
Standard Operating Procedure was adjusted to document counselor assistant supervision when working under direct observation.
A form was developed for counselors to use when supervising a counselor assistant under direct observation.
Clinical Supervisor and Chief Clinical Officer will ensure that these procedures are completed. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant, the facility failed to ensure that stored frozen food was kept at or below a temperature of 0 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on 2/5/2016, at approximately 1:00 pm. The inspection of the food storage areas found that four freezers showed a temperature higher than 0 degrees Fahrenheit.
The first freezer, located in the kitchen area, showed the temperature to be at 8 degrees. A review of the freezer log showed that this freezer was above 0 degrees daily on January 21-31, 2016 and February 1-4, 2016.
The second freezer, located in the lower level food storage area, showed the temperature to be at 10 degrees. A review of the freezer log showed that this freezer was above 0 degrees daily on January 21-31, 2016 and February 1-4, 2016.
The third freezer, located outside of a dormitory area, showed the temperature to be at 12 degrees. A review of the freezer log showed that this freezer was above 0 degrees daily on January 21-31, 2016 and February 1-4, 2016.
The fourth freezer, located outside of a dormitory area, showed the temperature to be at 6 degrees. A review of the freezer log showed that this freezer was above 0 degrees daily on January 21-31, 2016 and February 1-4, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All freezers were adjusted to below 0 degrees Fahrenheit.
Kitchen and facilities staff were informed of the requirement.
Staff were counseled on the importance of keeping frozen food at or below 0 degrees Fahrenheit.
Food Service Director will be responsible for reviewing freezer logs on a weekly basis to ensure that freezer temperatures remain below 0 degrees Fahrenheit. |
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 a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department of fire extinguisher company.
The findings include:
A physical plant inspection was conducted on February 5, 2016. A fire extinguisher located in an area outside of the counselor offices was last inspected in April 2014.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Extinguisher was moved to a more visible spot in the same area.
Fire Extinguisher location was added to the monthly safety check sheet.
Fire Extinguisher was replaced with another fire extinguisher that was currently inspected on the afternoon of 2/5/16.
Facilities Director will follow up to ensure that the above plan is implemented, and will review checklists on an ongoing basis. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
Fire Drill Logs were reviewed on February 5, 2016. Fire drill documentation was reviewed from January 2015 through December 2015. Based on the review of fire drill documentation, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Standard Operating Procedure was changed to require that sleeping hours fire drills shall not be completed until after 11:00 p.m., and must be completed before 6:00 a.m.
Fire Marshall was counseled on the importance of completing a fire drill during sleeping hours, and sleeping hours were clarified with all clinical staff.
Program Director (supervises front desk staff and fire marshal) will be responsible to ensure that fire drills are completed at the appropriate times. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the facility failed to document written acknowledgement that clients had been notified of client rights in one of ten client records reviewed.
The findings include:
Ten client records were reviewed on February 4-5, 2016. All clients receiving drug and alcohol treatment are required to be informed of their rights. A client rights form is presented to all clients for signature and this form is then documented in the client record. The facility failed to document written acknowledgement that the client has been notified of client rights in client record # 10.
Client # 10 was admitted into treatment on 7/29/15 and was discharged on 9/25/15. Written acknowledgement that the client had been notified of client rights was not documented in the client's record.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client was identified and his clients rights form was completed. Client had been informed of his rights, but had not signed the form.
The clients counselor was identified and counseled by the clinical supervisor on the importance of completing this form.
All counselors were addressed by the clinical supervisor in their weekly clinical staff meeting regarding the importance of completing all standard forms for every client.
Clinical Supervisor will be responsible to ensure that all counselors and counselor assistants are completing all required forms with their clients. Counselor will increase monthly case file reviews with this counselor assistant.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment services on the individual treatment and rehabilitation plan in eight of ten client records reviewed.
The findings include:
Ten client records requiring documentation of the frequency of treatment services on the individual treatment and rehabilitation plans were reviewed on February 4-5, 2016. The individual treatment and rehabilitation plans contained in client records # 2, 3, 4, 5, 6, 8, 9, and 10 did not include the frequency of treatment services.
Client # 2 was admitted into treatment on 1/1/16 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan, dated 1/22/16, did not specify the frequency of individual counseling therapy and group counseling therapy.
Client # 3 was admitted into treatment on 9/27/15 and was discharged on 11/30/15. The client's individual treatment and rehabilitation plan, dated 10/20/15, did not specify the frequency of individual counseling therapy and group counseling therapy.
Client # 4 was admitted into treatment on 11/1/15 and was discharged on 12/24/15. The client's individual treatment and rehabilitation plan, dated 11/18/15, did not specify the frequency of individual counseling therapy and group counseling therapy.
Client # 5 was admitted into treatment on 6/26/15 and was discharged on 8/28/15. The client's individual treatment and rehabilitation plan, dated 7/15/15, did not specify the frequency of individual counseling therapy and group counseling therapy.
Client # 6 was admitted into treatment on 8/2/15 and was discharged on 9/26/15. The client's individual treatment and rehabilitation plan, dated 8/18/15, did not specify the frequency of individual counseling therapy and group counseling therapy.
Client # 8 was admitted into treatment on 6/25/15 and was discharged on 8/28/15. The client's individual treatment and rehabilitation plan, dated 7/15/15, did not specify the frequency of individual counseling therapy and group counseling therapy.
Client # 9 was admitted into treatment on 7/31/15 and was discharged on 9/26/15. The client's individual treatment and rehabilitation plan, dated 8/20/15, did not specify the frequency of individual counseling therapy and group counseling therapy.
Client # 10 was admitted into treatment on 7/29/15 and was discharged on 9/25/15. The client's individual treatment and rehabilitation plan, dated 8/21/15, did not specify the frequency of individual counseling therapy and group counseling therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A template was updated to include frequency of treatment as well as modality.
All counselors were informed of the change during their weekly clinical staff meeting.
Individual counselors responsible were counseled on the importance of including frequency of treatment in their Individual Treatment Plans.
Clinical Supervisor will be responsible to follow up and maintain the above standard. Clinical Supervisor will continue to complete case file reviews for all counselors ensuring that this change has been made. |
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 ensure that a complete record on an individual that included information relative to the client's involvement with the project in four of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of a complete client record on February 4-5, 2016. The facility failed to document a complete record in client records # 2, 3, 4, and 7.
Client # 2 was admitted into treatment on on 1/1/16 and was still active at the time of the inspection. A record of service was not documented in the client's record.
Client # 3 was admitted into treatment on 9/27/15 and discharged on 11/30/15. The record of service for the client indicated the client attended a 1 hour group therapy session on 11/5/15. A progress note documented in the client's record indicated this group therapy session was canceled.
Client # 4 was admitted into treatment on 11/1/15 and discharged on 12/24/15. The record of service for the client indicated the client attended a group therapy session on 12/22/15. A progress note for this group therapy session was not documented in the client's record.
Client # 7 was admitted into treatment on 10/31/15 and was discharged on 12/26/15. The record of service for the client indicated the client attended a group therapy session on 12/22/15. A progress note for this group therapy session was not documented in the client's record. Additionally, the client's record of service failed to document the duration of service for individual counseling sessions attended by the client on the following dates: 11/6/15, 11/13/15, 11/18/15, 11/25/15, 12/1/15, 12/8/15, 12/15/15, and 12/22/15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since client #2 was still in active treatment, his counselor was able to add a record of service to the client file.
All counselors responsible were identified and counseled on the importance of completing a record of service for each client.
All counselors responsible were informed that they should take care when completing client notes.
Clinical Supervisor will increase case file reviews for counselors identified in this deficiency. Clinical Supervisor will continue to review case files for other counselors. A case file review includes each section of the clients file and looking to see if there are any pieces missing. This is completed for several files from each counselor monthly.
All counselors were addressed regarding deficiencies during weekly clinical staff meetings. |