INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19-22, 2013 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection the facility failed store all trash in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
During the physical plant inspection of the dining hall, a trash can was observed without a lid in the food preparation area. Kitchen staff confirmed that there was no lid to fit that trash can.
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Plan of Correction
Trash can will be replaced with a new trash can that has a lid with it. Maintenance of trash can and trash removal will be conducted by Dorm Supervisor/Maintenance. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection conducted on March 22, 2013, the facility failed to ensure that all utensils are stored in a clean enclosed area.
The findings include:
Cooking utensils were stored in an open area on hanging racks located above the food preparation area. All eating, drinking and cooking utensils must be stored in a clean, enclosed area.
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Plan of Correction
All utensils have been removed from hanging racks and placed in a transparent storage bin, which is located in a storage area of the kitchen. Dorm Supervisor/Maintenance will oversee storage and maintenance of kitchen equipment. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant, the facility failed to provide documentation of cold food being stored at or below 40 degrees Fahrenheit.
The findings include:
The kitchen was inspected on March 22, 2013. The facility had four refrigerators available for use, three of which were industrial sized appliances. The second refrigerator did not have an interior thermometer and the outer thermometer was reading 48 degrees Fahrenheit. The third refrigerator did not have an interior thermometer. The fourth refrigerator, which was a standard residential style kitchen appliance, did not have a thermometer.
The facility failed to provide documentation that a temperature log was completed. The Clinical Supervisor did not dispute the findings.
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Plan of Correction
Interior thermometers have been placed in all refrigerators. All refrigerators will have a log sheet posted on the door to document temperatures on a daily basis and will require Dorm Supervisor/Maintenance initials. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on an inspection of the physical plant, the facility failed to ensure that all food items are stored off of the floor.
The findings include:
The kitchen was inspected on March 22, 2013. During the physical plant inspection, potatoes and onions were observed on the floor in the dry storage area.
The clinical supervisor confirmed the findings.
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Plan of Correction
Shelving has been added to the dry storage area so that food items are off the floor by at least 6". Dorm Supervisor/Maintenance will add shelving as needed to ensure compliance. |
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 a physical plant inspection on March 22, 2013, the facility failed to ensure that the facility was free of portable space heaters.
The findings include:
There were two space heaters observed during the physical plant inspection. One was located in the bed room of support staff and the other was in the hallway of the basement.
The findings were confirmed by the clinical supervisor.
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Plan of Correction
All space heaters have been removed from the premises by Dorm Supervisor/Maintenance. Director and Dorm Supervisor/Maintenance will conduct a monthly inspection of support staff rooms, Dorm Supervisor/Maintenance will inspect belongings of new support staff and staff moving onto the campus to ensure that portable space heaters and other items not allowed do not enter the facility. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs, the facility failed to document the completion of monthly unannounced fire drills.
The findings include:
A review of the fire drill logs was conducted on March 22, 2013. The fire drill log was reviewed from the time period of March 2012 to February 2013. The facility failed to provide any documentation of fire drills conducted for the entire review period.
The findings were confirmed with the clinical supervisor.
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Plan of Correction
Completion of monthly unannounced fire drills resumed in March 2013 and will continue to be conducted and documented each month by Ddirector. |
705.10 (d) (2) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the fire drill logs, the facility failed to document the completion of fire drills during normal staffing conditions.
The findings include:
A review of the fire drill logs was conducted on March 22, 2013. The fire drill log was reviewed from the time period of March 2012 to February 2013. The facility failed to provide any documentation of fire drills conducted for the entire review period. Documentation of fire drills conducted during normal staffing conditions was missing for the entire review period.
The findings were confirmed with the clinical supervisor.
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Plan of Correction
Documentation of fire drills conducted during normal staffing conditions will be done by Director and kept on file by Administrative Assistant. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the review of administrative documentation and discussion with facility staff, the facility failed to document all components required for the fire drill log.
The findings include:
The fire drill logs for the twelve months prior to the inspection were reviewed on March 22, 2013. The facility did not include the time of the fire drill, how long it took to evacuate staff and clients or the details of problems encountered during the fire drills.
The clinical supervisor did not dispute the findings.
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Plan of Correction
Fire drills that are conducted monthly and at different times of the day will be logged by the Director and kept on file by the Administrative Assistant. The Fire Drill Log will include: Staff in charge, Date, Time of day, Time Elapsed, Number of individuals involved, Fire alarm/smoke detector operative, Exits used, and Problems encountered. |
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 logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
A review of the fire drill logs was conducted on March 22, 2013. Documentation of a fire drill conducted during sleeping hours is required once every six months. The facility did not document any fire drills during sleeping hours in the last twelve months.
The findings were confirmed by the clinical supervisor.
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Plan of Correction
Fire drills during sleeping hours will be conducted by Director every six months and will be documented in the Fire Drill Log and kept on file by Administrative Assistant. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to document the preparation of alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs was conducted on March 22, 2013. The fire drill log was reviewed from the time period of March 2012 to February 2013. The facility failed to provide any documentation of fire drills conducted for the entire review period. Documentation was missing for the preparation of alternate exit routes to be used during fire drills for the entire review period.
The findings were confirmed with the clinical supervisor
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Plan of Correction
The Fire Drill Log to be used includes a section for Exits used. Alternate exits will be included under this heading and will be logged in by Director and kept on file by Administrative Assistant. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the fire drill logs, the facility failed to document the completion of fire drills on different days of the week, at different times of the day and night and on different shifts.
The findings include:
A review of the fire drill logs was conducted on March 22, 2013. The fire drill log was reviewed from the time period of March 2012 to February 2013. The facility failed to provide any documentation of fire drills conducted for the entire review period. Documentation was missing for fire drills conducted on different days of the week, at different times of the day and night and on different shifts for the entire review period.
The findings were confirmed with the clinical supervisor
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Plan of Correction
Fire Drill Log to be used includes Time of day. Fire drills to be conducted at different times of day and on different shifts by Director will logged in under this heading and kept on file by Administrative Assistant. |
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 the fire drill logs, the facility failed to document that a fire alarm or smoke detector was set off during each fire drill.
The findings include:
A review of the fire drill logs was conducted on March 22, 2013. The fire drill log was reviewed from the time period of March 2012 to February 2013. The facility failed to provide any documentation of fire drills conducted for the entire review period.
Documentation of a fire alarm or smoke detector being set off during each fire drill was missing for the entire review period.
The findings were confirmed with the clinical supervisor
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Plan of Correction
Fire Drill Log to be used includes Fire alarm/smoke detector operative. Documentation that a fire alarm or smoke detector was set off and which alarm/detector was set off will be documented under this heading by the Director and kept on file by the Administrative Assistant. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual the facility failed to document inspections of the medication storage area.
The findings include:
The regulation requires an inspection of the medication storage area. The facilities policy states: "Director will perform inspections on a bi-monthly basis of the medication storage area to ensure that: external medication is stored separately from internal medication, outdated drugs are properly disposed of, medication log is being used properly and consistently, copies of procedures and memoranda related to medication control are properly posted." An inspection of the medication inspection storage area and the log book on March 22, 2013 failed to produce documentation of bi-monthly inspections.
The findings were confirmed by the clinical supervisor.
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Plan of Correction
A new Medication Inspection Log sheet has been posted above the medication cabinet that will document the Director's bi-monthly inspection of medications and the medication cabinet. Medication procedures will also be posted and a copy will be placed in the Medication Log Book. An inspection of the medication cabinet and medications has already been conducted and documented by the Director. |