INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on June 22, 2021 by staff from the 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection, the facility failed to keep the grounds in good repair at all times for the safety and well-being of residents. Emergency exit door located in the dining hall was observed to be missing the bracket allowing for the door to operate correctly. Furthermore, the ceiling light fixture in room 23 was observed to be detached for the ceiling hinges.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action-The screws were reinstalled into the bracket and secured on the emergency exit allowing the door to operate correctly.
Corrective Action- The screws were installed, and the light was fastened to the ceiling in room 23.
Date of Corrective action: 7/9/21
The maintenance manager has implemented monthly walk-throughs of the physical plant noting items that need repair. These items will then be sent to our ticket system for completion.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility exceeded its hot water temperature. Community bathroom located in the male residential area temperature reading was 131F.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action- The Furnace was adjusted, and water was tested 2 times both with readings under 120F
Date of Corrective action: 7/13/21
The maintenance manager has implemented monthly walk-throughs of the physical plant noting items that need repair. These items will then be sent to our ticket system for completion.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on the physical plant inspection, the facility failed to provide slip-resistant surfaces in all bathtubs and showers. Community bathroom located in the male residential area was noted to be missing slip-resistant surfaces.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action- Anti Slip Shower strips were installed in all showers throughout campus.
Date of corrective action: 7/20/21
The housekeeping team cleans showers daily and will notify the maintenance ticket system if or when strips need to be replaced or changed.
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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 the physical plant inspection, the facility failed to ensure proper functioning of exhaust fan in the bathroom located within the kitchen area and community bathroom located in the dining area.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action- Exhaust fans were purchased for both Kitchen and community bathrooms and installed.
Date of corrective action: 7/18/21
The maintenance manager has implemented monthly walk throughs of the physical plant noting items that need repair. These items will then be sent to our ticket system for completion.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection, the facility failed to maintain the up keep of the wall in the handicap stall located in the community bathroom in the dining area.
Bathroom wall was observed to be cracked.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action- The cracked laminate was removed, the area was fixed and painted on 7/20/21.
The maintenance manager has implemented monthly walk-throughs of the physical plant noting items that need repair. These items will then be sent to our ticket system for completion.
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705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on the physical plant inspection, the facility failed to provide a clean and disinfected area for food preparation.
A insect was observed on a food tray in the refrigerator.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action-Exterior doors will remain shut, Multiple fly traps have been placed outside by the exterior doors of the kitchen.
Date of corrective action: 7/13/21
The food service manager will enforce the doors remaining shut, periodically check fly trap replacing bait when needed, and making sure all areas are cleaned and disinfected.
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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 the physical plant inspection, the facility failed to store all food items off the floor.
Bread was observed to be stored on the floor in the kitchen area.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action- Addition and shelving and creates have been installed in the kitchen area in order to keep all food items off of the floor.
Date of Corrective action: 7/13/21
Foodservice manager has addressed his team and will add it to his weekly meeting, also while making daily checks.
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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 a physical plant inspection, the facility failed to ensure that there were no heaters that were not permanently mounted or installed. A space heater was discovered in an unmarked counseling office in the residential area.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective action- Facilities manager removed the space heater and all staff members were addressed.
Date of corrective action:7/19/21
The Operation Director and Director of Counseling Services implemented a walk-through process for the last Thursday of each month.
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection, the facility failed to ensure the facility was free of insect infestation.
Bathroom located within the kitchen was observed to be infested with files.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action-Exterior doors will remain shut, Multiple fly traps have been placed outside by the exterior and interior of the bathroom. The bathroom was thoroughly cleaned and disnfected.
Date of corrective action: 7/13/21
The food service manager will enforce the doors remaining shut, periodically check fly trap replacing bait when needed, and making sure all areas are cleaned and disinfected.
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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 a review of the facility fire drill records between October 2020 and May 2021, for November 2020 through May 2021 the facility failed to document the exit routes, and whether the fire alarm or smoke detectors was operative. Additionally, the logs for January & March 2021 failed to include problems encountered.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility form was updated to include: 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. Safety team staff were training on the process on 7/19/21. The Compliance Officer is in charge of implementation and auditing and will audit the records quarterly for Compliance and will conduct trainings as necessary. |
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 the facility fire drill records between October 2020 and May 2021, the facility failed to document a fire drill during sleeping hours at least every 6 months.
The last drill conducted during sleeping hours was documented April 27, 2021 at 11:05pm. No drills were conducted during sleeping hours between October 2020 through March 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility created an annual schedule for fire drills which includes two designated months for 3rd shift drill. (April and October) Out last overnight fire was held in April so our next one will be held in October in order to meet the 6 month compliance window.
Date of Corrective Action: 7/19/21
The Compliance Officer is in charge of implementation and auditing and will audit the records quarterly for Compliance and will conduct trainings as necessary. |
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 facility fire drill records between October 2020 and May 2021, the facility failed to document the exit routes used in November 2020 through May 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility added to the drill tracking form and area to indicate which alternate exit was used when an exit is being blocked.
Date of Corrective Action: 7/19/21
The Compliance Officer is in charge of implementation and auditing and will audit the records quarterly for Compliance and will conduct trainings as necessary. |
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 facility fire drill records between October 2020 and May 2021, the facility failed to document a fire alarm or smoke detector was set off during the months of October 2020, January 2021, and May 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility fire drill form was updated to include: A summary of which fire alarm or smoke detector was set off during each fire drill. Date of Corrective Action: 7/19/21
The Compliance Officer is in charge of implementation and auditing and will audit the records quarterly for Compliance and will conduct trainings as necessary. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of policies and procedures, the facility failed to document written procedures for the management of treatment/rehabilitation services for clients.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/13/21 the governing body reviewed and ensured that the documented written procedures for management/rehabilitation services in the policies and procedures were present and easily available. The compliance officer will review the policies and procedures quarterly to ensure the clinical team is following the policies and procedures. |
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 a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one out of three client records reviewed.
Client #1 was admitted on April 4, 2021 and was administratively discharged on May 16, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/22/2021 the clinical supervisor followed up with and trained the counseling team regarding the administrative discharge process. A review was completed of past administrative discharges and it was determined that this event was an exception, and typically the notice of administrative discharge form is completed. Monthly record reviews will be conducted by the clinical supervisor to maintain compliance. The client is no longer in the facility so this item could not be corrected. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of client records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered to the patient for detoxification treatment in two of four client records.
Client # 9 was admitted on June 21, 2021 and is still receiving services.
Client # 11 was admitted on January 29, 2021 & discharged on February 02, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Buprenorphine Consent forms are to be signed by the admitting Nurse during the admission process. Informed patient consent: Informed, voluntary, written consent will be obtained before buprenorphine is administered to any patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form.
On 7/13/21 all nursing NTP staff were trained on proper consent procedures. The nurse manager will conduct monthly record reviews to ensure compliance. at the time of the correction the staff connected with client 9 and was able to have the consent completed. client 11 was no longer in treatment and the consent could not be completed. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of client records, the facility failed to have a complete client record. Discharge summery was missing in one of four records.
Client # 11 was admitted on January 29, 2021 & discharged on February 02, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 7/13/21 the NTP case manager and nursing staff were retrained on the proper procedure for completing a discharge summary. The nurse manager will conduct monthly record reviews to ensure that proper procedures are followed. At the time of the correction the discharge summary was added to the record for client 11. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of client records, the facility failed to have a complete client record. Follow up was missing in one of four records.
Client # 11 was admitted on January 29, 2021 & discharged on February 02, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 7/13/21 the NTP case manager and nursing staff were retrained on the proper procedure for following up post-discharge. The nurse manager will conduct monthly record reviews to ensure that proper procedures are followed. The NTP case manager provided a follow up on 7/13/21 and documented it in the record. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project which includes progress notes in five of seven records.
Client # 2 admitted February 28, 2021 and discharged March 14, 2021. This record had incomplete progress notes on March 05, 2021, March 07, 2021, and March 08, 2021.
Client # 3 admitted December 19, 2020 and discharged January 30, 2021. This record had incomplete progress notes on December 23, 2020, December 24, 2020 and January 02, 2021.
Client # 4 admitted June 05, 2021. This record had incomplete progress notes on June 07, 2021, June 13, 2021 and June 16, 20201.
Client # 5 admitted June 07, 2021. This record had incomplete progress notes on June 15, 2021, and June 18, 2021.
Client # 7 admitted May 20, 2021. This record had incomplete progress notes on May 25, 2021, May 26, 2021 and June 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/15/2021 the Clinical Supervisor and Director of Resident Life completed individual training with relevant staff members on how to complete progress notes. Additionally, Clinical Supervisor will complete the monthly report in Electronic Health Record which will identify any incomplete Progress Notes and will then route for remediation. All missing progress notes were entered into the client records. |
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 client records, the facility failed to have a complete client record. Follow up information was missing in one of three applicable records.
Client # 1 was admitted on April 20, 2021 & discharged on May 16, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has scheduled training for the entire counseling team on July 29, 2021. This training will be emphasizing the clinical value and ethical responsibility associated with follow-up contacts. Counselor accountability increased by the clinical supervisor to review follow-up contact notes for each discharge patient chart for a period of 90 days. Record reviews will be conducted monthly by the Clinical Supervisor to ensure compliance. The follow up contact was conducted and the information was added to the record. |