INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6-7, 2023 by staff from the Department of Drug and Alcohol Programs, 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. 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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for the first 6 months of employment.
Employee #9 was hired on April 4, 2022 and was still employed at the time of the inspection. She had no documentation of the required close and direct supervision.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On 03/02/2023, The clinical supervisor was provided training related to the supervision of counselor assistants. The Director, in coordination with PAATC's Quality Assurance staff, will monitor staff supervision notes quarterly to ensure compliance with the standard. |
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 form, the facility failed to ensure that employee received the minimum of four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on February 7, 2022 and was due to have the communicable disease trainings no later than February 7, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 03/02/2023, training was provided to the Clinical Supervisor and Direct-Care manager regarding the need for all staff to comply with the training requirements outlined in 704.11(c)(1). All staff currently needing the TB/STD training have been scheduled to receive the required training on 04/27/2023. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilet and wash rooms by exhaust fan or window. The ventilation fan in the bathroom in the gym was inoperable.
This findings was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed 705.6(5) with the Facilities Director on 03/02/2023. The ventilation fan was repaired on 03/02/2023. The Facilities Director will complete quarterly walkthroughs of the facility to ensure compliance with physical plant standards. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in one out of ten records reviewed.
Patient #2 was admitted on January 20, 2023 and was still active at the time of the inspection. A consent form dated January 20, 2023 to a family member did not specify what information was to be disclosed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 03/02/2023, The Clinical Supervisor reviewed procedures for completing consent forms including indicating the information intended to be released. The Clinical Supervisor, in coordination with Quality Assurance staff, will conduct monthly audits and will monitor consent forms to ensure compliance with 709.28 (c) (2) |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in one out of ten records reviewed.
Client #2 was admitted on January 20, 2023 and was still active at the time of the inspection. A consent form dated January 20, 2023 to a family member and a funding source did not state the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 03/02/2023, The Clinical Supervisor reviewed procedures for completing consent forms including the purpose of disclosure. The Clinical Supervisor, in coordination with Quality Assurance staff, will conduct monthly audits and will monitor consent forms to ensure compliance with 709.28 (c) (23 |
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 the review of inpatient client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client records reviewed.
Client #10 was admitted on December 2, 2022 and discharged December 23, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 03/02/2023 staff was provided training related to the provision of notification of termination when clients are involuntarily discharged from treatment. The CA Manager, in coordination with Quality Assurance staff, will conduct monthly audits to ensure compliance with 709.33(a) |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of inpatient client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three records reviewed.
Client #9 was admitted on October 5, 2022 and was discharged on November 4, 2022.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 25, 2021 and March 11, 2022 licensing inspections.
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Plan of Correction
On 03/02/2023, the Discharge Summary for the above referenced client was completed. Training was provided to staff on 03/02/2023 regarding the necessity of having completed client records that include Discharge Summaries. Monthly chart audits will be completed by the Clinical Supervisor in coordination with Quality Assurance staff to ensure compliance with 709.53(a)(10). |
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 inpatient client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three records reviewed.
Client #9 was admitted on October 5, 2022 and was discharged on November 4, 2022.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 25, 2021 and March 11, 2022 licensing inspections.
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Plan of Correction
On 03/02/2023, the Follow-up Contact for the above referenced client was completed. Training was provided to staff on 03/02/2023 regarding the necessity of having completed client records that include Follow-up Contacts. Monthly chart audits will be completed by the Clinical Supervisor in coordination with Quality Assurance staff to ensure compliance with 709.53(a)(11). |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plan of corrections that were approved by the Department. A plan of correction for discharge summaries and follow-up information were submitted and approved by the Department for the March 11, 2022 and June 25, 2021 annual licensing inspections. Discharge summary and follow-up information were again found to be a deficiency in the February 7, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Monthly chart audits will be completed by the Clinical Supervisor in coordination with Quality Assurance staff to ensure compliance with 709.53(a)(11). Additionally, for the first 90 days of Case Management assisting with Follow-up Contacts, Case Managers will submit a list of Discharged Clients with completed Follow-Up Contacts to the Facility Director to ensure compliance. |