INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 14, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #4, who was hired as a counselor on April 11, 2022, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Lead Counselor, along with the Campus Supervisor, will immediately begin weekly supervision of employee #4 for 6 months, as per the staffing regs.
This supervision will include documentation of
1.) A weekly observation of either
a.) A group therapy session
b.) An individual therapy session
2.) A case review and discussion
|
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical site inspection, it was determined that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
Fire extinguishers located in the gym, hallway of sleeping area, and main floor common area did not have a current inspection tag.
This finding was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
On 3-2-23, the Campus supervisor contacted the fire extinguisher vendor to schedule for them to come and tag the three extinguishers in question.
This visit is scheduled for 3-6-23
Moving foward, the campus supervisor will work with the operations manager to ensure that a system is put in place to make sure all extinguishers on the property have current tags |
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.
|
Observations
Based on a review of fire drill logs from March 2022 through January 2023, the facility failed to conduct a fire drill during sleeping hours at least every six months.
A sleeping drill was conducted on April 23, 2022 and the next one was due no later than October 2022; however, no sleeping drill was completed.
This finding was reviewed with the facility staff during the licensing inspection.
This is a repeat citation from the March 24, 2022 and June 25, 2021 annual licensing inspections.
|
Plan of Correction
The campus supervisor will ensure that a sleeping time fire drill occurs, along with the regularly scheduled drill. The campus supervisor will be required to confirm via email to the executive director that a drill occurred each month.
furthermore, the fire drill logs will be separated into 2 logs, one for inpatient and one for outpatient, thus clarifying when each group is doing their drills |
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.
|
Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in five out of ten records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #2 was admitted on January 5, 2023 and was still active at the time of the inspection.
Client #5 was admitted on January 24, 2023 and was still active at the time of the inspection.
Client #6 was admitted on February 2, 2023 and was still active at the time of the inspection.
Client #7 was admitted on February 1, 2023 and was still active at the time of the inspection.
Client #10 was admitted on June 7, 2022 and discharged on September 6, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Lead counselor and the quality assistant will perform weekly chart audits on each new intake to ensure that the consent to release information to the funding source in included in every chart. The campus supervisor will check in weekly with the lead counselor to ensure that this task is being performed. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to document preliminary treatment plans within the guidelines established by the facility's policy and procedural manual in five out of seven records reviewed. The facility's policy and procedure manual states the preliminary treatment plan must be completed during intake.
Client #1 was admitted on January 5, 2023 and was discharged on February 4, 2023.
Client #2 was admitted on January 5, 2023 and was discharged on February 2, 2023.
Client #5 was admitted on January 24, 2023 and was still active at the time of the inspection.
Client #6 was admitted on February 2, 2023 and was still active at the time of the inspection.
Client #7 was admitted on February 1, 2023 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Lead counselor and the quality assistant will perform weekly chart audits on each new intake to ensure that the preliminary treatment plan is included in every chart. The campus supervisor will check in weekly with the lead counselor to ensure that this task is being performed. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on a review of client records, the facility failed to document that disclosure to the client of criteria for admission, treatment, completion, and discharge had taken place in five out of seven records reviewed.
Client #2 was admitted on February 2, 2023 and was still active at the time of the inspection.
Client #4 was admitted on December 29, 2022 and was still active at the time of the inspection.
Client #8 was admitted on August 19, 2022 and was discharged on November 21, 2022.
Client #9 was admitted on June 13, 2022 and was discharged on August 26, 2022.
Client #10 was admitted on June 7, 2022 and was discharged on September 6, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Lead counselor and the quality assistant will perform weekly chart audits on each new intake to ensure that the disclosure to the client of criteria for admission, treatment, completion, and discharge is included in every chart. The campus supervisor will check in weekly with the lead counselor to ensure that this task is being performed. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
|
Observations
Based on a review of client records, the facility failed to document that client orientation had taken place in five out of seven records reviewed.
Client #2 was admitted on February 2, 2023 and was still active at the time of the inspection.
Client #4 was admitted on December 29, 2022 and was still active at the time of the inspection.
Client #8 was admitted on August 19, 2022 and was discharged on November 21, 2022.
Client #9 was admitted on June 13, 2022 and was discharged on August 26, 2022.
Client #10 was admitted on June 7, 2022 and was discharged on September 6, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Lead counselor and the quality assistant will perform weekly chart audits on each new intake to ensure that the client orientation is included in every chart. The campus supervisor will check in weekly with the lead counselor to ensure that this task is being performed. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of outpatient client records, the facility failed to document preliminary treatment plans within the guidelines established by the facility's policy and procedural manual in four out of seven records reviewed. The facility's policy and procedure manual states the preliminary treatment plan must be completed during intake.
Client #1 was admitted on February 4, 2023 and was still active at the time of the inspection.
Client #2 was admitted on February 2, 2023 and was still active at the time of the inspection.
Client #4 was admitted on December 29, 2022 and was still active at the time of the inspection.
Client #8 was admitted on August 19, 2022 and was discharged on November 21, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Lead counselor and the quality assistant will perform weekly chart audits on each new intake to ensure that the preliminary treatment plan is included in every chart. The campus supervisor will check in weekly with the lead counselor to ensure that this task is being performed.
|
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four applicable records reviewed.
Client #3 was admitted on June 16, 2022 and was still active at the time of the inspection. A treatment plan update was completed on August 30, 2022 and the next update was due no later than October 30, 2022; however, it was completed on November 30, 2022.
Client #8 was admitted on August 19, 2022 and was discharged on November 21, 2022. A treatment plan update was due no later than October 19, 2022; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Lead counselor and the quality assistant will perform weekly chart audits on each new intake to ensure that the treatment plan updates are included in every chart within the regulatory timeframe. The campus supervisor will check in weekly with the lead counselor to ensure that this task is being performed.
|
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of three discharged records reviewed.
Client #8 was admitted on August 19, 2022 and was discharged on November 21, 2022.
Client #9 was admitted on June 13, 2022 and was discharged on August 26, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Lead counselor and the quality assistant will perform weekly chart audits on each new intake to ensure that the follow up information is included in each chart. The campus supervisor will check in weekly with the lead counselor to ensure that this task is being performed.
|
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.
|
Observations
Based on a review of fire drill logs, the facility failed to comply with plans of correction that were approved by the Department.
A plan of corrections for conducting a fire drill during sleeping hours at least every six months were submitted and approved by the Department for the June 25, 2021, and March 24, 2022 annual licensing inspections. Conducting a fire drill during sleeping hours was again found to be a deficiency in the February 14, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The executive director will personally ensure that once every six months a fire drill is conducted during sleeping hours. This will be clearly documented on the fire drill log presented during the next inspection. |