INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 21, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, Teen Challenge Training Center 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based upon observation by Licensing Staff, the the facility failed to ensure that there were no heaters within the facility that were not permanently mounted or installed.
The findings include:
Licensing staff met with the Clinical Supervisor in his office, on February 21, 2012. Upon entering the Clinical Supervisor's office, Licensing Staff observed a heater that was not permanently mounted nor installed.
The Clinical Supervisor confirmed the findings.
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Plan of Correction
On March 9, 2012, a memo was sent to all staff and support staff which Required the removal of all Portable Heaters the facility immediately. As of March 13, 2012 all portable heaters were removed by the maintenance department.
To prevent this from reoccurring Facility Manager will ensure that Portable Heaters not in the facility in the future. He will make periodic checks to assure that no portable heaters are anywhere in the facility.
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based upon an interview with the Intake Coordinator, a review of instructions posted on an office wall, a review of a facility document titled Bedbug Extermination and instructions on a bottle of insecticide, the facility failed to follow its own protocols by spraying clients with an insecticide for bedbugs.
The findings include:
Licensing staff interviewed the facility's Intake Coordinator on February 21, 2012. During the interview, the Intake Coordinator was asked to review the admission / orientation process for new clients. The Intake Coordinator stated that immediately upon arrival, all clients and their belongings are sprayed with redacted chemical name, an insecticide aimed at eliminating bed bugs. He said that the client stands just outside the intake office, fully clothed, and in the shape of a "T" with their legs together and their arms extended to the side at a 90 degree angle. The intake staff then create a "cloud or mist" of spray all around the client.
After the interview was concluded, Licensing Staff proceeded to inspect the intake office. During the inspection, Licensing Staff noticed a document that was posted on one of the walls that was titled Welcome Committee Instructions. The following instructions were a part of the document:
"Dry cleaning items just spray with 'redacted chemical name.'"
"Spray luggage, shoes, and all personal belongings with spray"
"Put personal items and hygiene back in luggage after spraying"
"When student is ready spray him lightly and have him shower"
"He needs to shower immediately after being sprayed."
Licensing Staff also noticed a bottle of redacted chemical name on a desk in the intake office. The following information was contained on the back label of the bottle: WARNING: Harmful if inhaled. Causes eye and skin irritation. Do not breath vapors or spray mist. Do not get in eyes. Avoid contact with skin.
Finally, Licensing Staff reviewed a facility policy regarding bedbugs, titled Bedbug Extermination, which included the following statement on the last page: "Redacted chemical name should not come in contact with the skin until it is fully dry."
Based upon the intake procedures described by the Intake Coordinator, the warnings on the back of the insecticide bottle and the instructions contained in the Bedbug Extermination document, the facility failed to ensure that clients were not sprayed with the bedbug insecticide.
Since the Clinical Director was not present during the interview with the Intake Coordinator, the findings were confirmed during the exit interview, via a three-way conference call, that included the Intake Coordinator, the Clinical Director, and the Licensing Specialist.
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Plan of Correction
In order to maintain that policy of Teen Challenge is implemented properly regarding the eradication of bedbugs in the Intake procedures, the Program Manager of Teen Challenge is responsible to train the Intake Coordinator to do and execute these procedures. This ongoing training will not only serve as immediate coaching for trainees, but will serve for future instruction as well. A video tutorial will be available by June 1, 2012 to assist in training other pertinent and future personnel regarding the eradication of pests such as bedbugs. Contained in the video is instruction not to spray the student with the chemical agent Steri-Fab, but rather spay the clothing once they have been removed and set aside. The policy manual "Bedbug Extermination" is also distributed to the trainees per course given. A Training Evaluation form is also presented to the trainees who in turn assess the instructor's teaching performance, knowledge on the issue, and if the training objectives were met. Upon completion of the instruction, the Training Evaluation form will be kept in the staff's file.
To prevent this from reoccurring The Program Manager will assure that all Intake Personnel will be trained in the future
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709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on dialogue with the Clinical Supervisor, the facility failed to include in its written policy that contraband would become property of the facility to dispose of as they see fit, including the possible auctioning off of the item. Additionally, the facility failed to inform clients of the project's full policies regarding the confiscation of client contraband during the orientation process.
The findings include:
Licensing staff engaged in ongoing dialogue with the Clinical Supervisor on February 21, 2012. During the dialogue, the Clinical Supervisor was asked to describe the facility's policies and practices regarding the confiscation of items considered to be contraband, i.e. cell phones, computers, and music players. The Clinical Supervisor explained that upon admission and orientation, clients are given the opportunity to turn in contraband items to facility staff so that the item(s) can be properly marked and stored. Items turned in voluntarily at admission are then returned upon a client's graduation from the program.
The Clinical Supervisor then explained that any contraband item that is turned in or confiscated after the admission / orientation process is complete automatically becomes property of the facility and is not returned to the client, even upon graduation from the program. The Clinical Supervisor then showed Licensing Staff a drawer that contained what appeared to be a variety of small electronic devices, which the Clinical Supervisor said were confiscated items that were not to be returned to clients. The Clinical Supervisor stated that the items were going to be sold at the upcoming Annual Benefit Auction, to be conducted from April 20 - 21, 2012.
When asked if there is a specific policy in place, either in the Policy & Procedures Manual or in the Client Handbook, the Clinical Supervisor searched through both and stated that none existed. When asked how clients are informed of the facility's policy and practices regarding contraband confiscated after admission, the Clinical Supervisor stated that clients are informed verbally.
Finally, Licensing Staff asked the Clinical Supervisor if he recalled confiscating a small or medium sized computer from any of the clients in the program. The Clinical Supervisor confirmed that in 2010 or 2011, he confiscated a medium sized electronic device from a former client, that could have been a small computer, and that was ultimately sold at the facility's Annual Benefit Auction.
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Plan of Correction
The Following notice was added to the student handbook on February 22, 2012.
NOTICE: All contraband which include electronic devices must to be turned over to the intake coordinator upon arrival at the Teen Challenge Training Center. You may ship items home at your expense. If you are not able to afford this or this is not an option then we will, in good faith, hold onto these items for you until you leave or complete the program. Any items that are found in the student's possession afterwards will be confiscated and become the property of Teen Challenge Training Center and will be disposed of at the programs discretion.
A notice will be given to every student to review and sign and date by May 18, 2012.
To prevent this from reoccurring new students entering the program after May 18, 2012 will be given a copy of the notice with attached to the handbook until new handbooks are printed. Intake director will be responsible to pass the above information out.
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