INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted between June 21 and 25, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Adult & Teen Challenge 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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704.11(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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of three employee records.
Employee #3 was hired on October 01, 2018 and was due to have the communicable disease trainings no later than October 2020. 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 facility staff during the licensing process.
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Plan of Correction
on 8/10/21 Employee #3 has be scheduled to complete training on September 14th for TB STD and HIV.
The PAATC Clinical supervisor will conduct a semiannual training assessment to make sure the employee annual training plan is adequate and adhered to in accordance to 704.11(c)(1) regulation.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill records between November 2020 and May 2021, the facility failed to document the exit route used between November 2020 through May 2021. Additionally, the logs for January 2021 and March 2021 failed to include problems encountered. Also, the logs between November 2020 through May 2021 failed to include whether the fire alarm or smoke detector was operative.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Safety Officer updated the Drill Sheet and trained the maintenance staff on the process on July 19, 2021 on how to document the exit route. Additionally, staff were trained to include problems encountered as well as to include whether the fire alarm or smoke detector was operative. The Compliance officer will audit annually for Compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility fire drill records between November 2020 and May 2021, the facility failed to document whether a fire alarm or smoke detector was set off between the months of November 2020 through May 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Safety Officer updated the Drill Sheet on July 19th to include how the alarm was set off (smoke detector or fire alarm). A review of the Fire Log will occur annually to ensure compliance by the Compliance Officer. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of policy and procedure and client records, the facility failed to document written procedures for the management of treatment/rehabilitation services for clients.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/2/21 the policy and procedures were reviewed and updated to ensure that procedures for management of treatment/rehabilitation services were present. The policies and procedures will be reviewed annually by our compliance officer to ensure compliance. |
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.
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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 prior to disclosure in two of seven client records.
Client # 3 was admitted on March 02, 2020 and was still active at the time of the inspection. This record did not include a release of information form for the funding source.
Client # 6 was admitted on March 23, 2021 and was still active at the time of the inspection. This record did not include a release of information form for the funding source.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #3 and Client #6 both signed a release of information for their funding source. Counselors were reminded of the standard in group supervision on 7/16/2021. Completion of an Authorization to Release Information for each clients funding source was added to the initial evaluation/assessment procedure, by use of a check box to remind counselors to check for this release, and complete one if missing. Clinical Supervisor added Funding Source Authorization to Release Information to monthly chart audit checklist, and will randomly check 12 chart monthly to ensure that releases are included. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to offer the client a copy of consents in one of seven records.
Client # 5 was admitted on March 26, 2021 and was still active at the time of the inspection. Releases of information were signed by the client but did not indicate a copy was offered.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the annual inspection conducted on October 1, 2020.
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Plan of Correction
A copy of release was provided to client number 5. Counselors were reminded of the standard on 7/16/2021. Individual counselor responsible for deficiency was addressed in individual supervision. Clinical Supervisor will follow up to check for compliance using monthly chart audits to ensure ongoing compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide treatment according to the individual treatment and rehabilitation plan in seven of seven client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Counseling Services addressed counseling team on 7/30/2021, explained the deficiency and outlined continuity of client records. Training for counselors specific to treatment planning and basing actual treatment on treatment plan scheduled for 9/3/2021. Qualitative audit of individual client chart was added to monthly chart audit checklist. Clinical Supervisor will assess charts for continuity of client record, ensuring that individual and group therapy sessions are directly related to client treatment plan. |
709.93(a)(11) LICENSURE Client records
709.93. 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 have a complete client record. Follow up information missing in two of two. applicable records.
Client # 1 was admitted on September 16, 2020 and was discharged on April 23, 2021. There was no documentation of follow up at the time of the inspection.
Client # 2 was admitted on September 14, 2020 and was discharged on May 18, 2021. There was no documentation of follow up at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor unable to make contact with Client #1. Counselor completed follow up contact with Client #2. Counselors reminded of standard on 7/16/2021, and specific counselors followed up with Clinical Supervisor in individual supervision. Clinical Supervisor will review random selection of charts monthly to ensure that 7-10 day follow up contact is completed. Patient 1 attempted contact on 5/25. Unable to reach client. Note was added 8/4.
Patient 2 follow up contact completed 5/25. Note added 8/4.
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