INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13-15, 2017 by staff from the Division of Drug and Alcohol 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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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
The facility failed to document that staff persons and volunteers received at least 6 hours of HIV/AIDS training and 4 hours of TB/STD training.
Training records were reviewed on March 13, 2017. Staff person #3 was hired as a counselor on 1/12/15. At the time of the inspection, staff #3 did not complete the required 6 hours of HIV/AIDS training. Individual #5 is a volunteer / intern and started on 9/27/14. Individual #5 did not have documentation of HIV/AIDS and TB/STD training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff person #3 was registered to take 6 hours of DDAP approved HIV/AIDS training on May 9, 2017 in Uniontown, PA. Facility Director will ensure that staff person attends this training and submits the completion certificate. Moving forward, the facility director will monitor all staff, employees and volunteers to ensure their compliance with having HIV/AIDS training. |
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
The facility failed to document the presence of a person certified in CPR during the project's hours of operation.
The facility's schedules and CPR cards were reviewed on March 13, 2017. Individual #5 provides overnight coverage two times per week. Individual #5's CPR certification expired on February 9, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency will be corrected by scheduling an onsite CPR/First Aid training. An onsite CPR/First Aid training has been scheduled for the last week of April in order to re certify individual #5. moving forward the Facility director will monitor that all 24 hours of operation are covered with staff that are CPR/First Aid trained. |
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.
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Observations
The facilty failed to conduct a fire drill during sleeping hours at least every 6 months.
The fire drill records were reviewed on March 13, 2017. The period of March 2016 - March 2017 was reviewed. The only fire drill during sleeping hours was conducted in June 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will meet with staff on April 10, 2017 and make a plan to ensure that moving forward 2 sleeping time fire drills will occur every calendar year. Moving forward, the facility director will do a monthly review of every fire drill to ensure that they are occurring and that two drills during sleeping time are occurring. |
709.28 (c) 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.
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Observations
The facility failed to document the purpose of disclosure on the informed and voluntary consent in 4 of 8 records reviewed.
Client records were reviewed on March 14-15, 2017. Client records # 3,4, 7 and 8 contained signed informed and voluntary consents which did not contain the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director updated The Confidential release of information document on April 10, 2017. The document was updated to include purpose of disclosure statements that can be checked off and initialed by the client. Moving forward the facility director will conduct monthly record reviews to ensure that the purpose of disclosure is clearly indicated in all confidential release of information. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to document the treatment plans were developed with the client in 5 of 8 records reviewed.
Client records were reviewed on March 14-15, 2017. Client records # 3, 4, 5, 7 and 8 contained treatment plans with no client signature and no progress note documenting the client's participation in it's development.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 10, 2017, the facility director updated The treatment plan document itself to include a signature block that the client must sign with the counselor to confirm that they were included in the treatment planning process. Moving forward the facility director will conduct a monthly record review to ensure that each client has participated in the formulation of their treatment plan. |
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
The facility failed to document treatment plan updates at least every 30 days in 2 of 6 records reviewed.
Client records were reviewed on March 14-15, 2017. All treatment plans are required to be reviewed/updated at least every 30 days. Client records # 3 and 4 contained treatment plans that were not reviewed/updated at least every 30 days.
Client #3 was admitted on 9/14/16 and discharged on 12/29/16. The last treatment plan review/update was completed on 11/14/16. There was no treatment plan review/update in December 2016.
Client #4 was admitted on 6/2/16 and discharged on 10/28/16. The last treatment plan review/update was completed on 9/21/16. There was no treatment plan review/update in October 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 11, 2017, the facility director met with the counseling team to discuss the necessity to ensure that a treatment plan update is included every 30 days in every client record. Moving forward, The facility Director will conduct a monthly review of client records takes place to ensure that treatment plan updates have been included every 30 days as required. Furthermore, in our weekly staff meetings and staff training it will be reinforced that we are to be sure to include treatment plan updates. |