INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's training records, the facility failed to conduct an annual evaluation of the overall training plan for training year January 1, 2021 through December 31, 2021.
The finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
The clinical supervisor has developed the annual training plan for training year Jan-Dec 2022 and it is currently on file as of this date. Furthermore, the facility director in consultation with the compliance department of PAATC will ensure that this plan is kept up to date moving forward |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to develop an individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor for training year January 1, 2022 through December 31, 2022.
Employee #2 was hired on December 1, 2014 and was still employed at the time of the inspection. The plan was not developed.
Employee #3 was hired on February 15, 2019 and was still employed at the time of the inspection. The plan was developed on March 17, 2022.
Employee #4 was hired on August 23, 2021 and was still employed at the time of the inspection. The plan was not developed.
Employee #5 was hired on February 1, 2021 and was still employed at the time of the inspection. The plan was developed on March 17, 2022.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
As of the date of this POC, the clinical supervisor has on file, an individual training plan for each employee for the training year 2022. Furthermore, the facility director in consultation with the compliance department of PAATC will ensure that the individual training plans are kept up to date moving forward |
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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #6 and #7 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor on September 14, 2020 and was due to have the communicable disease trainings no later than September 14, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #7 was hired as a clinical aide on April 1, 2019 and was due to have the communicable disease trainings no later than April 1, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were reviewed with project and facility staff during the licensing process.
This is a repeat citation from the June 25, 2021 licensing inspection.
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Plan of Correction
As of the date of this POC submission, all of the above employees either have obtained or are in the process of obtaining their current HIV/AIDS and TB/STD trainings.
Employee #6 has enrolled in the required training as of 4/27/22 and will have it completed by 5/9/22
Employee #7 has enrolled in the required training as of 4/27/22 and will have it completed by 5/9/22
Furthermore, under the oversight of the facility director, the clinical supervisor will keep an up-to-date staffing grid which tracks training compliance of all staff. The PAATC Quality Assurance department will conduct quarterly reviews of staffing grids and training files to ensure compliance with regulatory standards and internal policies for training and education. |
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 the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that the facility director completed at least 12 clock hours of training annually for training year January 1, 2021 through December 31, 2021.
Employee #2 was hired as a Facility Director on December 1, 2014 and was still in the position as of the date of the inspection. No training hours were documented.
The finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
The facility director will ensure that moving forward he gains the necessary 12 hours of annual training. Furthermore, the compliance department at PAATC will ensure that the facility director is gaining the necessary training hours thorough a quarterly check. |
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 a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as a camera was operating in the group counseling room.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This camera was immediately removed from the room when informed by licensing specialists. Facility Director will ensure that there are no cameras ever located in group counseling areas. |
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 a physical plant inspection, it was observed that the facility failed to maintain a bathroom in a functional, clean, and sanitary manner at all times. There was a torn chair and an electrical hand dryer that was defective in the residential bathroom.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The electrical hand dryer was immediately removed from the bathroom and disposed of. Facility director transitioned to a paper towel system for hand drying instead of using the electrical hand dryer moving forward. The torn chair was immediately disposed of and will be replaced by the facility director with a professional and well-kept barber chair. The facility director will conduct monthly walkthroughs of the facility to ensure bathrooms are being maintained in a functional, clean, and sanitary manner at all times |
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 from June 10, 2021 through February 7, 2022 the facility failed to conduct a fire drill during sleeping hours at least every six months.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 25, 2021 licensing inspection.
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Plan of Correction
The operations manager, under the oversight of the facility director will ensure that a fire drill during sleeping hours is conducted every six months. A drill during sleeping hours was conducted, at 1:00 am on 4-18-22. The facility director will audit the fire drill log quarterly to ensure compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, including the reason for termination in one out of two applicable records.
Client #9 was admitted on March 10, 2022 and discharged on March 22, 2022.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor, under the supervision of the facility director, will ensure that when a client is administratively discharged, that a reason for termination is delivered to the client in writing. The clinical supervisor will audit charts monthly to ensure compliance. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to document that the client shall have an opportunity to request reconsideration of a decision to terminate treatment in two out of two applicable records.
Client #9 was admitted on March 10, 2022 and discharged on March 22, 2022.
Client #11 was admitted on November 24, 2021 and was discharged on December 2, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor, under the supervision of the facility director, will ensure that when a client is administratively discharged, that an opportunity to request reconsideration of a decision to terminate is delivered to the client in writing. The clinical supervisor will audit charts monthly to ensure compliance. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to inform the Department of unusual incidents within the required three days. There were two occurrences on July 5 and 25, 2021 involving presence of ambulance personnel that were not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor, under the supervision of the facility director, will have a daily meeting with all shift leads to discuss any unusual incidents that happened the previous 24 hours. If an incident has occurred, it will be immediately documented and reported to DDAP. Furthermore, the compliance department at PAATC will perform a regular audit of the documentation and submission of unusual incidents. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one out of three discharged records reviewed.
Client #2 was admitted on February 17, 2022 and was discharged on February 28, 2022.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor, under the supervision of the facility director, will perform weekly audits of the charts to ensure that an aftercare plan is included in every record. The clinical supervisor will also ensure that each counselor is trained to include this when hired and regularly trained on this. The compliance dept at PAATC will also check the chart audits to ensure compliance. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three discharged records reviewed.
Client #2 was admitted on February 17, 2022 and was discharged on February 28, 2022.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor, under the supervision of the facility director, will perform weekly audits of the charts to ensure that documentation of follow up information is included in every record. The clinical supervisor will also ensure that each counselor is trained to include this at their weekly counselor meetings on Tuesday mornings. The compliance dept at PAATC will also check the chart audits to ensure compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in seven out of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The clinical supervisor, under the supervision of the facility director, will perform weekly audits of the charts to ensure that the type and frequency of treatment and rehabilitation services is included in every treatment plan. The clinical supervisor will also ensure that each counselor is trained to include this and it will be reviewed at the regular tuesday morning counselor meeting. The compliance dept at PAATC will also check the chart audits to ensure compliance. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not limited to, written documentation of proposed type of support services in seven out of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor, under the supervision of the facility director, will perform weekly audits of the charts to ensure that the proposed type of support services is included in every treatment plan. The clinical supervisor will also ensure that each counselor is trained to include this and it will be reinforced in the weekly tuesday morning counselor meeting. The compliance dept at PAATC will also check the chart audits to ensure compliance. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director immediately fixed the hours of operation, as the sign was faded by being in direct sunlight. Moving forward, facility director will purchase an hours of operation sign that is not written with marker, but has numbering and lettering that will not fade in sunlight. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display a telephone number to the general public for emergency purposes.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director immediately fixed the telephone number, as the sign was faded by being in direct sunlight. Moving forward, facility director will purchase an hours of operation sign that is not written with marker, but has numbering and lettering that will not fade in sunlight. This sign will include the emergency phone number |