INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 20-21, 2017 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:
|
Plan of Correction
|
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
|
Observations
The facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment.
Personnel records were reviewed on March 20, 2017. Employee # 3 was hired at the project in May 2016 as a clinical supervisor. There was no monthly supervision notes documented for employee #3.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
PA Code 704.6(e):
The Chief Clinical Officer met with this facility's DDAP licensing leadership committee to address and resolve the deficiency issue. The Chief Clinical Officer will require all Clinical Supervisors, for the first 6 months of employment, to participate in monthly meetings with their direct supervisor, the Chief Clinical Officer. These meetings will be designed to discuss all duties related to the Clinical Supervisor position as well as an ongoing performance review. The content of these meetings will include, but are not limited to, job requirements overview, personal and professional development, the goals of the position, organizational expectations, growth points, and overall performance reviews. All meetings and related points of discussion will be documented and kept in the Clinical Supervisor's file. Based on the skill level of the Clinical Supervisor, the Chief Clinical Officer will continue to conduct documented monthly meeting for ongoing support, development and performance overview. If needed, based on skill level of the Clinical Supervisor, these meeting will be increased in frequency to the need of the Clinical Supervisor. As required by DDAP, and as noted in the deficiency report, the Chief Clinical Officer will begin immediately conducting documented monthly meetings (as outlined above) with the Clinical Supervisor/Employee #3. The first documented monthly meeting will be conducted in April 2017. The facility will be in full compliance with the standard immediately ?effective April 11, 2017.
|
705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
|
Observations
The facility failed to ventilate each bathroom with a window or exhaust fan.
A physical plant inspection was conducted on March 21, 2017. During the time of the physical plant inspection, the exhaust fan in the bathroom near the nurses' station was found to be inoperable. There was no window in this restroom.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
PA Code 705.6(1):
The Facilities Director met with this facility's DDAP licensing leadership committee to address and resolve the deficiency issue. The Facilities Director will replace the bathroom fan in bathroom beside med station. He will start making monthly rounds effective immediately (Apr 2017) checking fans in all areas requiring ventilation to ensure there are functioning properly at all times. The facility will be in full compliance as these repairs will be made by the Facilities department, by 4/11/17
|
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.
|
Observations
The facility failed to document monthly unannounced fire drills.
The fire drill logs were reviewed on March 20 & 21, 2017. The period of March 2016 - February 2017 was reviewed. There were no fire drills conducted for the months of September and October 2016 as the fire alarm system was inoperable due to a lightening strike.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
PA Code 705.10 (d) (1):
The Fire Marshal & Fire Marsh Assistant met with this facility's DDAP licensing leadership committee to address and resolve the deficiency issue. The Fire Marshal & Fire Marsh Assistant will conduct Regular monthly fire drills with various time schedules. The Fire Marshal & Fire Marsh Assistant will document each fire drill accordingly. In the event that the fire alarm system is inoperable the Fire Marshal & Fire Marsh Assistant will document hourly rounds to ensure the safety of all members. All these documents will be kept in the Fire Marshal log book and a copy sent to the Chief Clinical Officer.
The Facility will be in full compliance with this standard immediately - Effective April 11,2017
|
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
|
Observations
The facility failed to document that the physician's verbal order was authenticated in writing by a physician or other medical professional authorized by law to prescribe medication.
Client records were reviewed on March 20-21, 2017. Client records #4 and 5 contained verbal orders from a physician that were not authenticated in writing.
Client record #4 contained a verbal order dated 2/2/17 that was taken by nursing staff. There was no written authentication by a physician or other medical professional authorized by law to prescribe medication.
Client record #5 contained verbal orders dated 3/2/17 and 3/6/17 that were taken by nursing staff. There was no written authentication by a physician or other medical professional authorized by law to prescribe medication.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility physician met with this facility's DDAP licensing leadership committee to address and resolve the deficiency issue. A policy and procedure has been developed in response to the deficiencies identified during the recent inspection of our facility. Implementation of these policies will take place immediately and it will be the responsibility of the Medical Director to ensure that they are fully complied with. The Medical Director will be responsible for the training of the nursing staff and each member of the medical staff (licensed providers, physicians and nurses) will need to complete a training module for ensuring compliance with these policies. This record of training will be maintained in their personnel file in the Human Resources office and updated annually. The staff training compliance officer will be responsible for ensuring the annual review process is completed yearly. A log of the training activity will be kept in the Human Resources office. This plan of correction has been implemented as of 04/11/2017. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
|
Observations
The facility failed to document inspections of the medication storage areas.
A physical plant inspection was conducted on March 21, 2017. The inspection documentation for the medication storage area was requested during the physical plant inspection. There was no documentation of the inspection of the medication storage area for the time period of February 2016 - March 2017.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility physician met with this facility's DDAP licensing leadership committee to address and resolve the deficiency issue. The facility was found to be deficient due to a lack of inspection and documentation of the medication storage area during the period February 2016 and March 2017. The following Policy and Procedure (SOP) for medication handling for the detox and short term program has been amended to reflect the need for periodic inspections of the medication storage area and documentation of this inspection in a log kept in the nursing station. Detailed in the SOP are the responsible individuals and suppliers who will conduct the inspections according to Federal and State Requirements. The medication storage and handling policy is detailed in this SOP. A policy and procedure will be implemented. Full compliance with the standard including an inspection of the medication storage area will be completed and documented within two weeks of the date of this document. The facility will be in full compliance for this: April 11, 2017 |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
|
Observations
The facility failed to file a written unusual incident report with the Department within 3 business days follow an incident involving an event at the facility requiring police, fire or ambulance personnel.
The incident reports for the time period of February 2016 - March 2017 were reviewed on March 21, 2017. An incident occurred on August 12, 2016 in which the police had to be called. There was no documentation that this incident report was submitted to the Department.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Program Director met with this facility's DDAP licensing leadership committee to address and resolve the deficiency issue. In this meeting Teen Challenge Training Center clinical team verified that our policy meet the DDAP standards. The Teen Challenge Training Center clinical team has scheduled a training for all of the clinical staff on 4/11/2017. This training will cover adherence to the Teen Challenge Training Center policy and DDAP standards on proper reporting of unusual incidents to the Department. Teen Challenge Training Center will conduct quarterly trainings for ongoing follow up to confirm that Teen Challenge Training center remains in compliance with PA code 709.34. The Clinical Program Director will be responsible for reporting all unusual incidents to DDAP. The Chief Clinical Officer is responsible for ensuring ongoing compliance. This plan for full compliance is effective 4/11/17. |