INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 30 - October 1, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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:
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection on September 30, 2020, the facility failed to keep the ground in good repair. The stairs handrail from the main building to the counselor building was loose.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10.1.2020 The maintenance team tightened the handrail and inspected it to make sure it was not loose. The maintenance team will add handrails to the monthly maintenance checklist and will regularly check to make sure the facility grounds are in good repair, maintaining compliance. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection on September 30, 2020, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The female residential unit's group room door was open during a group session. Individuals could be seen and heard from the hallway.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/14/2020 the program clinical supervisor conducted training with all of the clinical counselors regarding proper procedures for ensuring privacy during counseling sessions. The supervisor instructed all of the counselors to ensure the doors are closed during the counseling sessions and the privacy requirements are adhered to. The clinical supervisor will conduct monthly checks to ensure this is taking place. |
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.
|
Observations
Based on a physical plant inspection on September 30, 2020, the facility failed to keep water temperatures at or below 120F and ensure hot water was available throughout the facility. The sink in the kitchen had a hot water temperature of 144.6F. There was no hot water in the detox unit bathroom, female shower room, and men's rehab bathrooms #1 and 2.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The maintenance team will conduct monthly water temperature checks to ensure the water is below 120 F and above 80 F. These checks will include areas of the detox unit bathroom, female shower room, and men's rehab bathrooms #1 and #2 along with other areas of the facility. The maintenance team will add this to its monthly maintenance checklist and the director of maintenance will review it. as of 10/8/2020, the water temperature was at 105 F. |
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.
|
Observations
Based on a physical plant inspection on September 30, 2020, the facility failed to maintain a way to monitor food temperatures. The refrigerator and freezer in the female residential unit did not have thermometers for which to check food temperatures.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/01/2020 the program maintenance team installed thermometers in the refrigerator and freezer that were missing them. Then a safety check was conducted to ensure the temperatures for the refrigerators were at or below 40 F and freezers were at or below 0 F. |
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.
|
Observations
Based upon a physical plant inspection on September 30, 2020, the facility failed to store all food items off the floor. In the kitchen's walk-in freezer, boxes containing food were found to be on the floor.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/01/2020 the program maintenance team was trained on proper food storage procedures. Then a safety check was conducted to ensure all food items were stored off of the floor. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on the review of client records on September 30- October 1, 2020, the facility failed to document a completed informed and voluntary consent to release information form. In client record #'s 2, 6 and 7, "other" was checked for specific information to be disclosed without clarification on what other information could be released.
Client #2 was admitted on October 6, 2019 and discharged on December 13, 2019. The release of information form was dated October 6, 2019 and was to a funding source.
Client #6 was admitted on September 24, 2019 and discharged on October 25, 2019. Five releases of information forms all dated September 24, 2019 were for two friends, a government agency, a funding source and an emergency services organization.
Client #7 was admitted on February 8, 2020 and discharged on March 11, 2020. Three releases of information forms all dated February 8, 2020 were to a family member, a funding source and an emergency services organization.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/14/2020 the patients in mention completed and signed new consent to release information forms. These forms were completed correctly ensuring all pertinent information involving specific information to be disclosed was correct along with including the specific purpose for the disclosure. The forms were also documented to include offering a copy to the patient. On 10/14/2020 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2), (3), and 709.28 (d). The clinical supervisor will conduct monthly record audits inspecting for proper completion of the authorization to release forms. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on the review of client records on September 30- October 1, 2020, the facility failed to document a completed informed and voluntary consent to release information form which is to include purpose of disclosure in client record #'s 3, 6 and 8.
Client #3 was admitted on January 3, 2020 and discharged on February 8, 2020. A consent to release information form dated January 5, 2020 to a family member did not include the purpose of disclosure. In addition, a consent to release information form dated January 3, 2020 to a treatment facility had "other" checked for purpose of disclosure without clarification of other purposes.
Client #6 was admitted on September 24, 2019 and discharged on October 25, 2019. A consent to release information form dated September 30, 2019 to a government agency did not include a purpose. In addition, two consent to release information forms, one to a government agency and the other to a funding source, had "other" checked for purpose of disclosure without clarification of other purposes.
Client #8 was admitted on September 2, 2020 and was still active at the time of the inspection. A consent to release information form dated September 2, 2020 to a funding source had "other" checked for purpose of disclosure without clarification of other purposes.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/14/2020 the patients in mention completed and signed new consent to release information forms. These forms were completed correctly ensuring all pertinent information involving specific information to be disclosed was correct along with including the specific purpose for the disclosure. The forms were also documented to include offering a copy to the patient. On 10/14/2020 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2), (3), and 709.28 (d). The clinical supervisor will conduct monthly record audits inspecting for proper completion of the authorization to release forms. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on the review of client records on September 30- October 1, 2020, the facility failed to document that a consent form was offered to the client in client record #'s 9 and 10.
Client #9 was admitted on August 30, 2020 and was still active at the time of the inspection. Two consent to release information forms dated September 3, 2020 were to a lawyer and a government agency. An addition form dated September 17, 2020 was to a friend.
Client #10 was admitted on September 29, 2020 and was still active at the time of the inspection. a consent to release information form dated September 29, 2020 was to a pharmacy.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/14/2020 the patients in mention completed and signed new consent to release information forms. These forms were completed correctly ensuring all pertinent information involving specific information to be disclosed was correct along with including the specific purpose for the disclosure. The forms were also documented to include offering a copy to the patient. On 10/14/2020 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2), (3), and 709.28 (d). The clinical supervisor will conduct monthly record audits inspecting for proper completion of the authorization to release forms. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of client records on September 30-October 1, 2020, the facility failed to ensure that the clients had been made aware of their rights. The client rights signed by the clients did not include that they may not be discriminated against based on their sexual orientation in client record #'s 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
Client #1 was admitted on July 25, 2020 and discharged on August 7, 2020.
Client #2 was admitted on October 6, 2019 and discharged on December 13, 2019.
Client #3 was admitted on January 3, 2020 and discharged on February 8, 2020.
Client #4 was admitted on August 17, 2020 and discharged on September 17, 2020.
Client #5 was admitted on December 4, 2019 and discharged on December 12, 2019.
Client #6 was admitted on September 24, 2019 and discharged on October 25, 2019.
Client #7 was admitted on February 8, 2020 and discharged on March 11, 2020.
Client #8 was admitted on September 2, 2020 and was still active at the time of the inspection.
Client #9 was admitted on August 30, 2020 and was still active at the time of the inspection.
Client #10 was admitted on September 29, 2020 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/2/2020 the client's rights document was updated to include that they may not be discriminated against based on their sexual orientation along with Clients have the right to inspect their own records. The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. On 10/14/2020 the facility posted the new client's right document in the facility along with handing out the patients and having them sign a new copy of the new document. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
Based on a review of client records on September 30-October 1, 2020, the facility failed to ensure that the clients had been made aware of their rights. The client rights signed by the clients did not include that reasons for removing sections of their record prior to inspection shall be documented in client record #'s 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
Client #1 was admitted on July 25, 2020 and discharged on August 7, 2020.
Client #2 was admitted on October 6, 2019 and discharged on December 13, 2019.
Client #3 was admitted on January 3, 2020 and discharged on February 8, 2020.
Client #4 was admitted on August 17, 2020 and discharged on September 17, 2020.
Client #5 was admitted on December 4, 2019 and discharged on December 12, 2019.
Client #6 was admitted on September 24, 2019 and discharged on October 25, 2019.
Client #7 was admitted on February 8, 2020 and discharged on March 11, 2020.
Client #8 was admitted on September 2, 2020 and was still active at the time of the inspection.
Client #9 was admitted on August 30, 2020 and was still active at the time of the inspection.
Client #10 was admitted on September 29, 2020 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/2/2020 the client's rights document was updated to include that they may not be discriminated against based on their sexual orientation along with Clients have the right to inspect their own records. The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. On 10/14/2020 the facility posted the new client's right document in the facility along with handing out the patients and having them sign a new copy of the new document. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
Based upon a physical site inspection on September 30, 2020, the facility failed to ensure that drugs requiring special conditions were kept separately from other items. In the female residential unit medication room refrigerator, food was observed to be stored in the refrigerator for staff consumption.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/30/2020 all of the staff food items were removed from the refrigerator. On 10/10/2020 the medical staff was instructed during a staff meeting to store their personal food items in the staff refrigerator in the breakroom and the medical refrigerator was only to store medications for the patients. The medical staff will conduct monthly inspections to ensure the medication storage areas remain in compliance with 709.32 (c) (3) (i) - (v). |
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
Based on a review of unusual incidents reported to the Department, the facility failed to file written unusual incident reports within three business days. An incident that occurred on April 6, 2020 was not reported to the Department until April 23, 2020. In addition, sixteen unusual incidents were reported on August 14, 2020 for incidents that occurred on April 24, May 4, May 20, May 25, June 13, June 21, June 29, June 30, July 18, July 25, July 27, August 4, August 5, August 7, August 12 and a second one for August 12, 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/1/2020 PAATC facilitated training with the clinical supervisors on proper unusual incident reporting procedures 709.34 (c) (1). During this training, we made a special note of the timeframe of 3 business days to submit the report. PAATC has also added this to our annual QIP summary for continued follow up. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on a review of client records on September 30 - October 1, 2020, the facility failed to document a consultation between the doctor who performed the patient examination and the doctor who prescribed the initial dose of medication in client record #'s 5 and 8.
Client #5 was admitted on December 4, 2019 and discharged on December 12, 2019.
Client #8 was admitted on September 2, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/8/2020 PAATC medical director facilitated training with the medical providers on proper consultation procedures regarding the determination of the patient's initial dose according to 715.15(b). If the provider who examines the patient is not the provider assigning the initial dose of medication, then they will consult with the original provider and enter a progress note in the patient record outlining the conversation. |