INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21-26, 2021 by staff from the 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.
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Plan of Correction
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704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and the employee work schedule, the facility failed to have awake staff coverage 24 hours a day.
No staff were scheduled 7 days a week between 6:00am and 7:00am and again between 4:30pm and 10:00pm.
No overnight staff were scheduled on Sundays and Mondays.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review the staff schedule and ensure that all 24 hours are covered by having a weekly meeting with all department heads to ensure that there is available staffing for 24/7 coverage.
A weekly document will be created by the clinical supervisor which contains the schedule showing 24/7 coverage and this document will be filed.
This will be followed up by the facility director on a monthly basis to ensure compliance |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 6 hours of HIV/AIDS training and 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training for two support staff.
A support staff hired on July 23, 2018 was due to have the communicable disease trainings no later than July 2020. There was no documentation of these trainings in the personnel file on the date of the inspection.
A support staff hired on April 01, 2019 was due to have the communicable disease trainings no later than April 2021. There was no documentation of these trainings in the personnel file on the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will assist support staff in question to register for HIV/AIDS & communicable disease training by the end of July 2021. The facility Director will follow up to make sure this is completed.
The facility director will follow up on a monthly basis for compliance and will advise the clinical supervisor to alert him when the training in completed.
The clinical supervisor will also add to the orientation process for new clinical staff the requirement to get these required trainings. |
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 the Staffing Requirements Facility Summary Report and a review of personnel records, the facility failed to document CPR certification for a sufficient number of staff persons, so that at least one person trained in CPR is onsite during the hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will ensure that the 24/7 staff schedule includes at least one CPR/First aid certified person on site at all times.
The facility director will follow up on a monthly basis to ensure compliance.
The clinical supervisor will also, on a monthly basis, ensure that current staff get recertified when their CPR/first aid expires, and that new staff are given first aid/CPR training.
The facility director will follow up monthly to ensure compliance. |
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 each bathroom in a functional manner.
A shower head in the male residential bathroom was loose and in need of repair.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 7-23-21, the facility director, along with a maintenance worker, secured the showerheads so that it is no longer loose.
Facility director will follow up August 30, 2021 to make sure it is still secure. |
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 fire drill records between April 2019 and June 2021, the facility failed to conduct fire drills during sleeping hours at least every 6 months.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will ensure that in the month of August 2021, there will be a sleeping hours fire drill. This will be documented in the fire drill log. The facility director will check for compliance.
The clinical supervisor will ensure that moving forward there will be one fire drill during sleeping hours every six months.
The facility director will follow up monthly to ensure fire drill compliance, including sleeping hours. |
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 records between April 2019 and June 2021, the facility failed to document if the fire alarm or smoke detector were set off during each fire drill.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
During the August 2020 fire drill, The clinical supervisor will ensure that a smoke detector is tested during this drill. The facility supervisor will check for compliance.
Moving forward the clinical supervisor will ensure that each month either a fire alarm or smoke detector are tested during each drill.
Facility director will follow up monthly to ensure this has been done. |
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 policy and procedure, 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
The facility director, in consultation with the clinical supervisor, will write policy and procedures for management of treatment/rehab services for clients. This will be added to the current policy and procedure manual.
The facility director will follow up to ensure this is finished.
The clinical supervisor will retrain the clinical staff on these policies and procedures.
The facility director will review records monthly to ensure compliance with these policies. |
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 and an interview with project director, the facility failed to document physical examinations of clients in three of seven records.
Client # 1 was admitted on June 17, 2021
Client # 2 was admitted on May 31, 2021
Client # 7 was admitted on May 04, 2021 and discharged on May 07, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will audit charts of every client to ensure that physical examinations are performed and included in each chart. This audit will be performed biweekly, and each audit will include 6 records.
The facility director will follow up on monthly to make sure this has been done. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to review and update client treatment plans at least every 15 days in three of seven records.
Client # 4 was admitted on June 02, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 03, 2021 and the next update was due no later than June 18, 2021; however, there was no update documented in the record at the time of the inspection.
Client # 5 was admitted on March 25, 2021 and was discharged on April 21, 2021. A treatment plan update was completed on March 25, 2021 and the next update was due no later than April 09, 2021; however, there was no update documented in the record at the time of the inspection.
Client # 6 was admitted on April 21, 2021 and was discharged on May 19, 2021. A treatment plan update was completed on April 21, 2021 and the next update was due no later than May 06, 2021; however, there was no update documented in the record at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will instruct the clinical staff to correct these records by August 15, 2021. He will re audit the files to ensure compliance. The facility director will follow up to ensure compliance.
The clinical supervisor will audit these charts on a biweekly basis and ensure compliance with the treatment planning regulations.
The facility director will follow up on a monthly basis to ensure compliance. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in one of three applicable records.
Client # 6 was admitted on April 21, 2021 and was discharged on May 19, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the clinical supervisor will instruct the clinical team to fix the records in question by August 15, 2021. The facility director will follow up to ensure compliance.
Clinical supervisor will audit charts of counselors on a biweekly basis to ensure that discharge summaries are included in each record in a timely manner. At least 6 records will be checked each time.
The facility director will follow up on a monthly basis to ensure compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of three applicable records.
Client # 7 was admitted on January 6, 2021 and discharged on February 10, 2021.
The findings were reviewed with the facility staff during the licensing process
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Plan of Correction
The clinical supervisor will instruct the clinical staff to correct this record.
Clinical supervisor will audit charts on a biweekly basis and ensure that aftercare plans are included in every chart. 6 charts will be checked each time.
The facility director will follow up on a monthly basis to ensure compliance. |
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.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of three records.
Client #5 was admitted on January 15, 2021 and discharged on April 30, 2021.
Client #6 was admitted on January 29, 2021 and discharged on May 20, 2021.
Client #7 was admitted on January 21, 2021 and discharged on February 10, 2021.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
The clinical supervisor will instruct the clinical staff to correct these records by August 15, 2021. The facility director will follow up to ensure compliance.
Biweekly, the clinical supervisor will audit 6 charts to ensure that follow up documentation is included in every chart consistently.
Facility director will follow up on a monthly basis to ensure compliance. |