INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 22 through February 25, 2011 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 and a plan of correction is due on March 22, 2011.
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Plan of Correction
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704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
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Observations
Based on a review of the staffing requirements facility summary report form completed by the facility on February 22, 2011 and a discussion with administrative staff, the facility failed to document that counselor assistants were eligible for a caseload.
The findings included:
On February 22 and 23, 2011, three counselor assistant caseloads were reviewed on the facility summary report form. Per regulation, counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
Employee # 7 was hired on January 3, 2011 as a counselor assistant. Employee #7
was still under direct observation but was carrying a caseload of five clients.
This was discussed with administrative staff on February 25, 2011. Staff confirmed that employee #7 was still under direct observation and should not be carrying a caseload.
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Plan of Correction
Original Transcripts of counselor #7 were faxed to Teen Challenge Training Center on February 28, 2011 and were reviewed by the state's inspector and it was agreed that he could now have a case load. In order to prevent this oversight from reacuring, case loads will no longer be assigned to any counselor and/or assistant counselor until Human Resources confirms with the Clinical Supervisor that all verification of Professional licensure or registration is received and documented in the employee's file. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based on a review of personnel records and a discussion with administrative staff, the facility failed to document verification of degree in one of eight personnel records, as required by regulation.
The findings include:
Eight personnel records were reviewed on February 22 and 23, 2011. Eight personnel records required verification of degrees. Per regulation, the personnel records shall include the verification of training experience and professional licenses, where applicable. Personnel record #8 did not include verification of professional licensure or registration.
Employee # 8 was hired on May 31, 2010 2010. There was no documentation of professional licensure or registration in the personnel record.
A discussion was held with administrative staff on February 25, 2011 and confirmed there was no verification of professional licensure or registration documented for employee #8.
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Plan of Correction
The high school transcripts of counselor #8 was received by Teen Challenge Training Center on February 28, 2011. In order to prevent this in the future, case loads will no longer be assigned to any counselor and/or assistant counselor until Human Resources confirms with the Clinical Supervisor that all verification of training shall be noted, professional licensure and or registration is received and documented in the employee's file. |