INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24-26, 2016 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(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to consistenly utilize a mechanism to collect feedback on completed training in two of five personnel records reviewed.
The findings include:
Five personnel records requiring documentation of feedback on completed training were reviewed on February 24-25, 2016. The facility failed to provide documentation of training feedback for personnel records # 1 and 2.
Employee # 1 is the facility director and started in this position on 12/1/14. Feedback on completed training was not documented in the employee's record.
Employee # 2 was hired as a counselor on 4/27/09. Feedback on completed training was not documented in the employee's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director, will make sure that all staff trainings have the appropriate evaluation form attached to it. This will be accomplished through a monthly file check. |
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 provide documentation of individual training plans in one of six personnel records reviewed.
The findings include:
Six personnel records were reviewed for the documentation of individual training plans on February 24-25, 2016. The facility failed to provide documentation of an individual training plan, for the current training year, in personnel record # 6.
Employee # 6 was hired on 10/01/01 and is currently in a maintenance position. The facility failed to provide documentation of an individual training plan for this employee.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will personally make sure that the maintenance position will have a fully developed individual training plan. |
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, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of five personnel records reviewed.
The findings include:
Five personnel records requiring documentation of HIV/AIDS and TB/STD training were reviewed on February 24-25, 2016. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel record # 5.
Employee # 5 was hired as a counselor on 1/12/15. HIV/AIDS and TB/STD training was due to be completed no later than 1/12/16. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director will make sure that employee #5 gets his HIV/AIDS, TB/STD trainings. This will be accomplished by August 1st, 2016. Employee #5 will immediately research available options for local organization that offer these trainings. |
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 a physical plant inspection, the facility failed to 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 findings include:
A physical plant inspection was conducted on February 26, 2016. In a 2nd floor resident bathroom, it was observed that the lower portion of a dividing wall column between two shower stalls had deterioration due to water damage. The damaged area presented with peeling paint and loosened baseboard trim, exposing the wood underneath it.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director and maintenance manager removed the section of the column in question and replaced it with new material. It was additionally sealed with waterproof caulking to prevent this from happening again. |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection, the facility failed to maintain at least one fire extinguisher in each kitchen.
The findings include:
A physical plant inspection was conducted on February 26, 2016. It was observed that a kitchen in a staff living area, located on the first floor of the facility, did not contain a fire extinguisher. This kitchen is located in the same building used to house clients, and it contains a cooking area.
The findings were discussed with staff during the licensing process.
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Plan of Correction
The Maintenance manager purchased a fire extinguisher and it is now hanging in the forementioned kitchen. The extinguisher has a current tag and has an ABC rating. |
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 informed and voluntary consents from the client for the disclosure of information contained in the client record in one of eight client records reviewed.
The findings include:
Eight client records requiring documentation of a informed and voluntary consent were reviewed on February 25, 2016. The facility failed to document informed and voluntary consents in one client record, specifically record # 4.
Client # 4 was admitted into treatment on 8/17/15 and was still active at the time of the inspection. A consent to release information to a probation officer, signed and dated by the witness on 8/20/15, did not document the dated signature of the client. The client's record documented that a progress note was sent to the probation officer on 11/23/15. Additionally, the client's record documented that a progress note was sent to a different probation officer on 2/19/16. A consent to release information to the second probation officer was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will be responsible for maintaining compliance with this standard. This will be achieved by means of a monthly audit of all files of active clients by the director. During each weekly staff meeting, the director will remind counseling staff of maintain compliance with this standard. The identified client's file was not able to be fixed here since the client transferred to the second phase, however his counselor at the second phase was contacted to ensure that his confidential releases were in compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of patient records, the facility failed to document a physical examination as part of the intake procedures in three of eight client records reviewed.
The findings include:
Eight client records were reviewed on February 25, 2016. All records were reviewed for the documentation of a physical examination as part of the intake procedures. Client records # 3, 4, and 7 did not document that a physical examination had been completed as part of the intake procedures.
Client # 3 was admitted into treatment on 10/16/15 and was still active at the time of the inspection. There was no documentation in the client's record that a physical examination had been completed during the intake procedures.
Client # 4 was admitted into treatment on 8/17/15 and was still active at the time of the inspection. There was no documentation in the client's record that a physical examination had been completed during the intake procedures.
Client # 7 was admitted into treatment on 6/25/15 and was discharged on 7/25/15. There was no documentation in the client's record that a physical examination had been completed during the intake procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The director will contact the admissions office at the Rehrersburg site to make sure that every incoming client has a completed physical exam form. Director will train the clinical staff through monthly checks of client records and discussion at weekly staff meeting. Continued compliance will be achieved through the director checking that each new client has the appropriate paperwork. |
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 a review of client records, the facility failed to document a treatment plan update at least every 30 days in four of eight client records reviewed.
The findings include:
Eight client records were reviewed on February 25, 2016. Six of these client records required documentation of treatment plan updates. The facility failed to document a treatment plan update at least every 30 days in client records # 2, 3, 4, and 8.
Client # 2 was admitted into treatment on 11/13/15 and was still active at the time of the inspection. The last treatment plan update for the client was completed on 1/16/16. The next treatment plan update was due to be completed by 2/16/16 and this update was not documented in the client's record.
Client # 3 was admitted into treatment on 10/16/15 and was still active at the time of the inspection. The last treatment plan update for the client was completed on 1/16/16. The next treatment plan update was due to be completed by 2/16/16 and this update was not documented in the client's record.
Client # 4 was admitted into treatment on 8/17/15 and was still active at the time of the inspection. The individual treatment and rehabilitation plan for the client was completed on 9/17/15. The first treatment plan update for the client was due to be completed by 10/17/15. The only documented treatment plan update for the client was completed on 1/18/16.
Client # 8 was admitted into treatment on 5/30/15 and was discharged on 11/11/15. The individual treatment and rehabilitation plan for the client was completed on 6/12/15. The first treatment plan update for the client was due to be completed by 7/12/15. The only documented treatment plan update for the client was completed on 10/26/15.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation, as the facility was cited for non-compliance of this standard during the previous licensing renewal inspection, on February 19, 2015.
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Plan of Correction
All the appropriate counselors were shown these deficiencies in their client records. Staff training will be performed at weekly staff meeting. Counselor's files will be checked monthly by the director to ensure compliance. Clients 2,3,4, and 8 are all still in treatment and their files were all brought into compliance. |
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 to include information relative to the client's involvement with the project was documented in eight of eight client records reviewed.
The findings include:
Eight client records were reviewed for documentation of a complete client record during the renewal inspection on February 25, 2016. The facility failed to document a complete record in client records # 1, 2, 3, 4, 5, 6, 7, and 8.
Client # 1 was admitted into treatment on 1/16/16 and was still active at the time of the inspection. The record of service for the client indicated the client attended group counseling sessions on 1/25/16, 2/7/16, 2/14/16, and 2/21/16. Progress notes for these group counseling sessions were not documented in the record. Progress notes in the record indicated the client attended group counseling sessions on 2/8/16, 2/15/16, 2/22/16. These group counseling sessions were not documented on the record of service. Additionally, the client's record of service for the month of January 2016 did not document the provider of individual counseling sessions and group counseling sessions.
Client # 2 was admitted into treatment on 11/13/15 and was still active at the time of the inspection. The record of service for the client indicated the client attended an individual counseling session on 11/25/15 . A progress note for this individual counseling session was not documented in the record. The record of service also indicated the client attended group counseling sessions on 11/23/15 and 2/15/15. Progress notes for these group counseling sessions were not documented in the record. A progress note documented in the record indicated the client attended a group counseling session on 2/16/16. This group counseling session was not documented on the record of service. Additionally, the record of service for the client did not document the provider of individual counseling sessions and group counseling sessions.
Client # 3 was admitted into treatment on 10/16/15 and was still active at the time of the inspection. A progress note documented in the client's record indicated the client attended an individual counseling session on 1/14/16. This individual counseling session was not documented on the record of service. The record of service indicated the client attended group counseling sessions on 11/2/15, 1/28/15, 2/7/16, 2/14/16, and 2/21/16. Progress notes for these group counseling sessions were not documented in the client's record. Additionally, the record of service did not document the provider of individual counseling sessions and group counseling sessions.
Client # 4 was admitted into treatment on 8/17/15 and was still active at the time of the inspection. The record of service for the client indicated the client attended individual counseling sessions on 8/20/15, 8/24/15, and 8/27/15. Progress notes for these individual counseling sessions were not documented in the client's record. The record of service also indicated the client attended group counseling sessions on the following dates: 9/14/15, 9/21/15, 11/2/15, 11/9/15, 11/16/15, 12/7/15, 12/28/15, 1/4/16, 1/11/16, and 1/18/16. Progress notes for these group counseling sessions were not documented in the client's record. Additionally, the record of service for the client did not document the provider of individual counseling sessions and group counseling sessions.
Client # 5 was admitted into treatment on 12/14/15 and was discharged on 1/7/16. The record of service for the client did not document the provider of individual counseling sessions and group counseling sessions.
Client # 6 was admitted into treatment on 7/10/15 and was discharged on 10/31/15. The record of service for the client indicated the client attended an individual counseling session on 10/7/15. A progress note for this individual counseling session was not documented in the record. The record of service also indicated the client attended a group counseling session on 9/7/15. A progress note for this group counseling session was not documented in the record. A progress note documented in the record indicated the client attended a group counseling session on 9/8/15. This group counseling session was not documented on the record of service. Additionally, the record of service for the client did not document the provider of individual counseling sessions and group counseling sessions.
Client # 7 was admitted into treatment on 6/25/15 and was discharged on 7/25/15. The record of service for the client indicated the client attended an individual counseling session on 7/8/15. A progress note for this individual counseling session was not documented in the record. A progress note in the client's record indicated the client attended an individual counseling session on 7/15/15. This individual counseling session was not documented on the record of service. A progress note in the client's record indicated the client attended a group counseling session on 6/29/15. This group counseling session was not documented on a record of service, as a record of service for the month of June 2015 was not documented in the client's record. Additionally, the record of service for the client did not document the provider of individual counseling sessions and group counseling sessions.
Client # 8 was admitted into treatment on 5/30/15 and was discharged on 11/11/15. The record of service for the client indicated the client attended group counseling sessions on the following dates: 7/6/15, 9/21/15, 9/28/15, 10/5/15, 10/12/15, 10/19/15, 10/26/15, 11/2/15, and 11/9/15. Progress notes for these group counseling sessions were not documented in the client's record. A progress note documented in the record indicated the client attended a group counseling session on 7/7/15. This group counseling session was not documented on the record of service. Additionally, the record of service for the client did not document the provider of individual counseling sessions and group counseling sessions.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation, as the facility was cited for non-compliance of this standard during the previous licensing renewal inspection, on February 19, 2015.
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Plan of Correction
All the counselors were met with to discuss their record of services and documenting services. As this was both a repeat offense from last inspection and it included all of the client records, the director will review all files on a monthly basis to ensure compliance. |