INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2012 to March 8, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Teen Challenge Training Center Inc. 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 facility's administrative material and a personnel record, the facility failed to document weekly supervision notes of the clinical supervisor providing direct observation with the counselor assistant.
Also, based on a review of the facility's administrative material and a personnel record, the facility failed to document supervision notes that include a reference to the charts of the clients that the counselor assistant counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted.
The findings include:
On March 7, 2012, the facility's administrative material and a personnel record requiring documentation of weekly supervision notes of the clinical supervisor giving direct observation to the counselor assistant were reviewed. Also, on March 8, 2012, the facility's administrative material and personnel records requiring documentation of weekly supervision notes that include a reference to the charts that the counselor assistant counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted were reviewed. The facility did not provide documentation of weekly supervision notes of the clinical supervisor providing direct observation with the counselor assistant in four of four personnel records reviewed, specifically, personnel records # 7, 8, 10 and 11. Also, the facility did not provide documentation of supervision notes that included a reference to the charts of clients that the counselor assistant counsels under close supervision or the charts that are discussed with the counselor assistant demonstrating that at least one hour per week of direct observation is being conducted.
Employee # 7 was hired May 2, 2011 and has a G.E.D. The facility was required to provide documentation of weekly supervision notes of the clinical supervisor providing direct observation with employee # 7. Also, the facility was required to provide documentation of supervision notes that included a reference to the charts of clients that the counselor assistant counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted. However, the facility's administrative material and personnel record # 7 only included documentation of supervision notes of the clinical supervisor providing direct observation with employee # 7 from 5/4/11 to 1/30/12. Also, all of the supervision notes did not include a reference to the charts of clients that employee # 7 counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted.
Employee # 8 was hired January 3, 2012 and has an Associates Degree in Liberal Arts. The facility was required to provide documentation of weekly supervision notes of the clinical supervisor providing direct observation with employee # 8. Also, the facility was required to provide documentation of supervision notes that included a reference to the charts of clients that was discussed with the counselor assistant under close supervision demonstrating that at least one hour per week of direct observation is being conducted. However, the facility's administrative material and personnel record # 8 only included documentation of supervision notes of the clinical supervisor providing direct observation with employee # 8 from 2/13/12 to 1/6/12. Also, all of the supervision notes did not include a reference to the charts of clients that employee # 8 counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted.
Employee # 10 was hired as a counselor assistant on October 14, 2011 and has an Associates Degree in Liberal Arts. The facility was required to provide documentation of weekly supervision notes of the clinical supervisor providing direct observation with employee # 10. Also, the facility was required to provide documentation of supervision notes that included a reference to the charts of clients that the counselor assistant counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted. The facility did provide supervision notes from 10/17/11 to 3/7/12. However, all of the supervision notes did not include a reference to the charts of clients that employee # 10 counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted.
Employee # 11 was hired as a counselor assistant on June 20, 2011 and has an Bachelors of Arts Degree in Bible. The facility was required to provide documentation of weekly supervision notes of the clinical supervisor providing direct observation with employee # 11. Also, the facility was required to provide documentation of supervision notes that included a reference to the charts of clients that the counselor assistant counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted. However, the facility's administrative material and personnel record # 11 only included documentation of supervision notes of the clinical supervisor providing direct observation with employee # 11 from 6/20/11 to 1/5/12. Also, all of the supervision notes did not include a reference to the charts of clients that employee # 11 counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted.
The findings were confirmed during an ongoing dialogue with the facility director on March 7, 2012 from approximately 1:00 P.M. to 2:00 P.M.
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Plan of Correction
Beginning on March 14, 2012 Clinical Supervisor or Lead Counselor will document weekly the direct suoervision with a supervision note indicating the when the direct observation was done for at lease an hour with whom and indicate by way of roster # which student and student chart was supervised by observation. Documentation will be kept on file by the Clinical Supervisor or Lead Counselor for up to 1 year for each assistant counselor.
To prevent this from reoccurring the Program Director will follow-up with Clinical Supervisor who will ensure the completion of this task by cosigning the documentations.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, first aid cards and Cardio Pulmonary Resuscitation (CPR) certifications, the facility's staff work schedule from February 6, 2012 to March 8, 2012, the facility failed to ensure that a sufficient number of staff persons in first aid and CPR skills are present during all the project's hours of operation.
The findings include:
On March 7, 2012, the facility's personnel records were reviewed. Also, on March 8, 2012, the facility's first aid cards, CPR certifications, and staff work schedule from February 6, 2012 to March 8, 2012 were reviewed. The facility did not have documentation of staff persons with first aid training and current CPR certification from 7 A.M. to 4:00 P.M. on the following dates: 2/16/2012; 2/7/2012; 2/8/2012; 2/9/2012; 2/10/2012; 2/13/2012; 2/14/2012; 2/15/2012; 2/16/2012; 2/17/12; 2/21/2012; 2/22/2012; 2/23/2012; 2/24/2012; 2/27/2012; 2/28/12; 2/29/2012; 3/1/2012; 3/15/2012; 3/6/2012; 3/7/2012; and 3/8/2012.
Also, the facility did not have documentation of staff persons with first aid training and current CPR certification during the following times and dates: 1) 11:00 P.M. on 2/10/2012 to 7:00 A.M. on 2/11/2012; 2) from 11:00 P.M. on 2/11/2012 to 7:00 A.M. on 2/12/2012; 3) from 3:00 P.M. to 11:00 P.M. on 2/12/2012; 4) 11:00 P.M. on 2/17/2012 to 7:00 A.M. on 2/18/2012; 5) from 7:00 A.M. to 3:00 P.M. on 2/18/2012; 6) from 11:00 P.M. on 2/24/2012 to 7:00 A.M. on 2/24/2012, 6) from 11:00 P.M. on 2/25/2012 to 7:00 A.M. on 2/26/2012; 7) from 7 A.M. to 11:00 P.M. on 2/26/2012; 8) from 7:00 A.M. to 4:00 P.M. on 2/27/2012; and 9) from 11:00 P.M. on 3/3/2012 to 7:00 A.M. on 3/3/2012.
In addition, the facility did not have documentation of staff persons with first aid training and current CPR certification on 3/2/2012.
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Plan of Correction
The program manager of Teen Challenge will ensure that the program assistant will schedule a full-time staff person with CPR and first aid certification be present on the campus during all the hours of operation. This will be done by creating a schedule that will be posted with the individual's name with time/date scheduled. This schedule will be posted at the front desk, and on the Academic Staff community bulletin board just outside the Program Manager's office. All staff will also be notified of their schedule through inter-office mailing and e-mail dissemination.
The Director of Operations will schedule any staff who is not certified to become certified at the nearest CPR/First Aid training location. This will begin as soon as possible.
To prevent this from reoccurring, the Program Manager will instruct the program assistant to document all persons with CPR and First Aid certification on their monthly shift schedules. These schedules will be created and disseminated through e-mail and inter-office mail once a month. The program manager will make certain that a documented list of CPR and first aid staff members will be readily assessable as well.
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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 on observations on March 8, 2012, the facility failed to ensure that heaters that are not permanently mounted or installed were not permitted in the facility.
The findings include:
A physical plant inspection was conducted on March 8, 2012. It was observed during the inspection at approximately 10:30 A.M., that there was a portable space heater in a cubicle located in the public relations area of Wilkerson Hall. Also, it was observed at approximately 12:15 P.M., that there was a portable space heater in the facility's medical office.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on March 8, 2012 from approximately 10:30 A.M. to 12:20 P.M.
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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 they are not placed in rooms or offices.
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705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on an interview with the clinical supervisor and director of operations, the facility failed to provide written procedures for staff and residents to follow in case of an emergency for the evacuation and transfer of residents impaired by alcohol or other drugs.
The findings include:
On March 7, 2012 and March 8, 2012, the Licensing Specialist asked to see the facility's written procedures for staff and residents to follow in case of an emergency for the evacuation and transfer of residents impaired by alcohol or other drugs. Written procedures for staff and residents to follow in case of an emergency for the evacuation and transfer of residents impaired by alcohol or other drugs was not presented for review.
The findings were confirmed during an ongoing dialogue with clinical supervisor and director of operations on March 8, 2012 from approximately 9:00 A.M. to 10:00 A.M.
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Plan of Correction
Written procedures for staff and residents to follow in case of an emergency for evacuation and transfer of residents impaired by alcohol or other drugs was added to the emergency procedures.
Fire Marshall or Assistant Fire Marshall shall be responsible to make sure that staff and residents follow evacuation and transfer of residents impaired by alcohol to remain in place hereafter.
Fire Marshall or Assistant Fire Marshall shall be responsible to ensure that the written procedures for staff and residents to follow in case of an emergency for evacuation and transfer of residents impaired by alcohol or other drugs remain in place at the facility.
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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 records, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
Fire drill records were reviewed on March 8, 2012. The records were reviewed from the period covering March 2011 to February 2012. The facility's sleeping hours are from 10:30 P.M. to 6:15 A.M. Monday, Tuesday, Wednesday, and Thursday and from 11:00 P.M. to 8:00 A.M. Friday, Saturday, and Sunday. The facility documented a fire drill during sleeping hours on May 15, 2011 at 6:00 A.M. The next drill during sleep hours would have been due on or before November 15, 2011. However, the next fire during sleep hours was not documented by the facility until January 30, 2012 at 10:45 P.M.
The findings were confirmed during an ongoing dialogue with clinical supervisor on March 8, 2012 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
A fire drill will be performed at least every 6 months while the students are sleeping. The fire marshal and assistant fire marshal shall schedule this to occur 6 months in advance.
To prevent this from reoccurring assistant fire marshal and fire marshal shall be responsible to ensure that this policy is upheld.
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to provide documentation that they set off a fire alarm or smoke detector during each fire drill.
The findings include:
Fire drill records were reviewed on March 8, 2012. The records were reviewed from the period covering March 2011 to February 2012. On July 25, 2011 the facility did not have documentation for whether or not they set off a fire alarm or smoke detector during the fire drill.
The findings were confirmed during an ongoing dialogue with clinical supervisor on March 8, 2012 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
Assistant fire marshal shall schedule fire drills 6 months in advance. When fire drills are completed, he will check to ensure that the fire drill report is completed in its entirety.
Clinical supervisor reviewed new fire drill report and trained 26 staff on paperwork procedures showing them how it is to be completed properly. On April 5, 2012 training was provided to the changes to the policy and procedures as well as the "Fire Drill Report" Attendance was taken and evaluations were completed by all staff in attendance.
To prevent this from reoccurring clinical supervisor shall retrain staff on the fire drill Report and remind them of all procedures twice per year to ensure that standards are being met.
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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 fire drill records, the facility failed to maintain a written fire drill record that included documentation of the exit route used, the number of persons in the facility at the time of the drill, problems encountered, and/or whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records were reviewed on March 8, 2012. The records were reviewed from the period covering March 2011 to February 2012. The facility did not have documentation for exit route used in eleven of twelve months reviewed, specifically, March 7, 2011; April 20, 2011; May 5, 2011; June 24, 2011; July 25, 2011; August 31, 2011; September 7, 2011; November 18, 2011; December 8, 2011; January 30, 2012; and February 27, 2012. Also, the facility did not have documentation for problems encountered in two of twelve months reviewed, specifically, March 7, 2011 and July 25, 2011. In addition, the facility did not have documentation for the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative in one of twelve months reviewed, specifically, July 25, 2011.
The findings were confirmed during an ongoing dialogue with clinical supervisor on March 8, 2012 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
The Fire Marshall and or Assistant Fire Marshall will be responsible for making sure that the facility maintain a fire drill record that will include documentation of the exit route used, the number of persons in the facility at the time of the drill, problems encountered, and/or whether the fire alarm or smoke detector is operative.
To prevent this deficiency from reoccuring in the future the Fire Marshall and or Assistant fire marshall shall review all documentation submitted after a fire drill to assure it is completed entirely. To prevent this from reoccurring, this will become part of the training provided by the Teen Challenge Training Center to staff every two years.
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709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on observations on March 8, 2012, the facility failed to have a fee schedule posted in a prominent place.
The findings include:
A physical plant inspection was conducted on March 8, 2012. It was observed during the inspection at approximately 11:30 A.M. that the facility did not have a fee schedule posted in a prominent place.
The findings were confirmed during an ongoing dialogue with clinical supervisor on March 8, 2012 from approximately 11:30 A.M. to 1:00 P.M.
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Plan of Correction
Intake fee has been posted in the intake office in plain view.
To prevent this from reoccurring, the Clinical Supervisor and Intake Manager will make sure fee schedule remain postedat the facility.
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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 a review of client records, the facility failed to document a physical examination or document a physical examination in with their policy and procedures.
The findings include:
The facility's policy titled: "Physical Examination," states:
"Prior to admission, the student shall receive a physical examination."
On March 8, 2012, five records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination according to their policy and procedures in one of five records reviewed, specifically, client record # 1. Also, the facility did not document a physical examination in two of five records reviewed, specifically, client records # 2 and 4.
Client # 1 was admitted January 27, 2012. The physical examination was due prior to admission. The physical examination was completed; however, the physical examination did not include a date of completion.
Client # 2 was admitted January 28, 2012. The physical examination was due prior to admission. However, client record # 2 did not include documentation of a physical examination as of March 8, 2012.
Client # 4 was admitted January 28, 2012. The physical examination was due prior to admission. However, client record # 4 did not include documentation of a physical examination as of March 8, 2012.
The findings were confirmed during an ongoing dialogue with clinical supervisor on March 8, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
As a result of our recent inspection deficiency, Teen Challenge has taken a look at our current policy as it pertains to students being requiring to have a physical examination prior to coming to our program. We have made a change to our policy that keeps this rule in place as a norm, however it allows for an exception to be granted for students who have special circumstances or problems that hinders them from having a physical examination prior to coming. Students who have been granted an exception will be accepted into our program with a stipulation that they have no more than 30 days to acquire a proper physical examination. Students who fall into this new category will be monitored for compliance by the medical department. This change does not reflect the norm, but the exception. The medical department staff will schedule these students for appointments and will annotate in the student's file any progress that has been made toward compliance. This policy change is effective immediately as an interim policy and will submitted to our governing board for approval at the next meeting.
The phyicical exam for stunt # 2 has been completed. Student # 4 was discharged from the program
In order to assure this does not reoccur, the medical department and Intake director will ensure that all students who are enrolled in our program will have a completed physical examination within the new required 30 day period. They will ensure that our current deficiency will not occur again in the future.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation or document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment.
The findings include:
The facility's policy on psychosocial evaluations indicates that the psychosocial evaluation is to be completed within the first fifteen business days of treatment.
On March 8, 2012, five client records requiring documentation of psychosocial evaluations were reviewed. The facility did not document a psychosocial evaluation that included an assessment of client's assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment in three of five records reviewed, specifically, client records # 2, 3, and 4. Also, the facility did not document a psychosocial evaluation in one of five records reviewed, specifically, client record # 5.
Client # 2 was admitted January 28, 2012. The psychosocial evaluation was completed on February 7, 2012. However, the psychosocial evaluation did not include an evaluation of the client ' s assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment.
Client # 3 was admitted January 28, 2012. The psychosocial evaluation was completed on February 7, 2012. However, the psychosocial evaluation did not include an evaluation of the client ' s support systems and coping mechanisms, and attitude toward treatment.
Client # 4 was admitted January 28, 2012. The psychosocial evaluation was completed on February 7, 2012. However, the psychosocial evaluation did not include an evaluation of the client ' s assets/strengths and support systems.
Client # 5 was admitted January 28, 2012. The psychosocial evaluation was due on or before February 24, 2012. However, client record # 5 did not include documentation of a psychosocial evaluation as of March 8, 2012.
The findings were also confirmed during an ongoing dialogue with the clinical supervisor on March 8, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
Clinical supervisor will provide training to the counselors and assistant counselors who failed to provide psychosocial assessments of clients. This will be completed by May 9, 2012
This training will consist of assessing assets/strengths, support systems, coping mechanisms, negative factors and attitude towards treatment.
The Psycho-social assessment of student #5 has been completed by the counselor and reviewed by the Clinical Supervisor.
To Prevent this from reoccurring, Clinical Supervisor will require all psychosocial evaluation's to be turned over for his review and he will sign and date them after the review is completed.
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709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on a review of an interview with the clinical supervisor, the project failed to assists clients in obtaining dental supportive services when necessary.
The findings include:
On March 7, 2012 and March 8, 2012, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining dental supportive services when necessary. Documentation that the facility assists clients in obtaining dental supportive services when necessary was not presented for review.
The findings were confirmed during an ongoing dialogue with clinical supervisor on March 8, 2012 from approximately 9:00 A.M. to 10:30 A.M.
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Plan of Correction
A cooperative agreement with a local dentist to provide dental services will be completed and kept on file, being renewed every two years hereafter.
To prevent this from reoccurring, clinical supervisor will review, yearly, all cooperative agreements.
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service.
The findings include:
On March 8, 2012, five records requiring documentation of a record of service were reviewed. The facility did not document a record of service in two of five records reviewed, specifically, client records # 2 and 5.
Client # 2 was admitted January 28, 2012. The facility was required to have a record of service in client record # 2. However, client record # 2 did not include documentation of a record of service as of March 8, 2012.
Client # 5 was admitted January 28, 2012. The facility was required to have a record of service in client record # 5. However, client record # 5 did not include documentation of a record of service as of March 8, 2012.
The findings were confirmed during an ongoing dialogue with clinical supervisor on March 8, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
Clinical supervisor will provide training to the counselors and assistant counselors who failed to provide record of service for clients.
For student #2 the record of service has benn completed. Student #5 has also been completed.
To prevent this from reoccurring, clinical supervisor will review one file of a counselor monthly, review will continue for 6 months consistently with proven success and then be reviewed quarterly. Clinical supervisor will check every file during his training session with his Assistant counselor's to ensure proper completion.
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