INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 14, 2012 to March 15, 2012 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedures manual, the project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the overall training plan to address staff training needs.
The findings include:
The facility's policy titled: "Staff Training Procedures Teen Challenge of Western Pennsylvania," states:
"Every year at the beginning of October the director and staff will meet to assess staff training needs for the upcoming year. By the end of October the director will develop training plans for staff based upon the feedback from the other staff. Staff will provide written feedback upon completion of training. An annual evaluation will be written by the director based upon the written feedback from the staff. The written feedback sheets turned into the director by staff will be placed in their individual folders by the director."
The facility's policies and procedures on their staff development program were reviewed on March 15, 2012 and March 16, 2012. The policy and procedures presented as the policy and procedures on staff development for the facility did not include who is responsible and the time for completion of the overall training plan to address staff training needs.
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Plan of Correction
The Western PA policy on staff development will be revised by the project director by May 15th and presented to the board for approval by the project director on May 17th 2012.The facility director will be responsible to ensure that the revised policy (once approved)remains at the facility once it is approved by the board. |
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 facility's Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff.
The findings include:
On March 14, 2012 and March 15, 2012, the facility's Staffing Requirements Facility Summary Report form were reviewed to verify that staff had HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. Based on the Staffing Requirements Facility Summary Report form, the facility did not ensure that volunteers that are support staff receive HIV/AIDS and STD training within two years of starting at the facility, specifically, volunteers/support staff # 11, 12, 13, 14, 15 and 16.
Volunteer/Support Staff # 11 is a volunteer that is a guest teacher and started on January 5, 1992. Volunteer/Support Staff # 11 would have been due to complete HIV/AIDS and STD/TB training by January 5, 1994. However, based on the facility's Staffing Requirements Facility Summary Report form completed on March 6, 2012, volunteer/support staff # 11 has not completed HIV/AIDS and STD/TB training as of March 15, 2012.
Volunteer/Support Staff # 12 is a volunteer that is a guest teacher and started on February 4, 1999. Volunteer/Support Staff # 12 would have been due to complete HIV/AIDS and STD/TB training by February 4, 2001. However, based on the facility's Staffing Requirements Facility Summary Report form completed on March 6, 2012, volunteer/support staff # 12 has not completed HIV/AIDS and STD/TB training as of March 15, 2012.
Volunteer/Support Staff # 13 is a volunteer that is a chapel speaker and started on September 13, 1997. Volunteer/Support Staff # 13 would have been due to complete HIV/AIDS and STD/TB training by September 13, 1999. However, based on the facility's Staffing Requirements Facility Summary Report form completed on March 6, 2012, volunteer/support staff # 13 has not completed HIV/AIDS and STD/TB training as of March 15, 2012.
Volunteer/Support Staff # 14 is a volunteer that is a chapel speaker and started on October 7, 2005. Volunteer/Support Staff # 14 would have been due to complete HIV/AIDS and STD/TB training by October 7, 2007. However, based on the facility's Staffing Requirements Facility Summary Report form completed on March 6, 2012, volunteer/support staff # 14 has not completed HIV/AIDS and STD/TB training as of March 15, 2012.
Volunteer/Support Staff # 15 is a volunteer that is a chapel speaker and started on January 5, 1990. Volunteer/Support Staff # 15 would have been due to complete HIV/AIDS and STD/TB training by January 5, 1992. However, based on the facility's Staffing Requirements Facility Summary Report form completed on March 6, 2012, volunteer/support staff # 15 has not completed HIV/AIDS and STD/TB training as of March 15, 2012.
Volunteer/Support Staff # 16 is a volunteer that is a chapel speaker and started on January 4, 1992. Volunteer/Support Staff # 16 would have been due to complete HIV/AIDS and STD/TB training by January 4, 1992. However, based on the facility's Staffing Requirements Facility Summary Report form completed on March 6, 2012, volunteer/support staff # 16 has not completed HIV/AIDS and STD/TB training as of March 15, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 9:00 A.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on March 8, 2011 for noncompliance with this standard.
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Plan of Correction
The facility director will be overseeing having the HIV and TB/STD trainings done by one of our volunteers in house using the approved curriculum. This will take place no later than June 3o 2012. All volunteers and staff who need these trainings will be contacted by the facility director over the next 3-5 days to arrange dates that will work for all who need the trainings. Any volunteers or staff unable to take theses trainings will be removed from there positions here at Teen Challenge until they are able to get the trainings. As new staff and volunteers come to work at this facility the facility director will oversee making sure that all of these individuals get the required HIV and TB trainings within the first year of service by scheduling in house trainings and making sure they attend them. |
705.1 (2) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
Based on an interview with the facility director and administrative assistant, the facility failed to provide a certificate of occupancy for the facility's gym.
The findings include:
On March 15, 2012, the Licensing Specialist asked to see a copy of the certificate of occupancy for the facility's gym. A copy of the certificate of occupancy for the facility's gym was not presented for review.
The findings were confirmed during an ongoing dialogue with the facility director and administrative assistant on March 15, 2012 from approximately 9:50 A.M. to 10:00 A.M.
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Plan of Correction
The facility director has closed the gym as of 3/15/2012. The facility director has called the labor department numerous times and they say they are on it but have not said when it will happen. When it is approved the facility director will be responsible for making sure the certificate of occupancy remains in place at this facility. |
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.
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Observations
Based on a physical plant inspection, the facility failed to ensure that hot food was served at or above 140 F.
The findings include:
A physical plant inspection was conducted on March 15, 2012. During the inspection, the Licensing Specialist asked to see a food serving temperature log. A food serving temperature log was not presented for review; therefore, there was no way to determine if hot food at the facility had been served at or above 140 F.
The findings were confirmed during an interview with the administrative assistant on March 15, 2012 at approximately 10:30 A.M.
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Plan of Correction
The kitchen supervisor will be responsible for ensuring that the facility serves hot food at 140 F or above and the facility director will be responsible for ensuring that this happens as of 4/26/2012. Food temps will be taken by the cook at each meal where hot food is served using a bi metal thermometer. The cook will record these temps at serving time and turn the form in weekly to the kitchen supervisor. |
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 observations on March 15, 2012, the facility failed to ensure that heaters that are not permanently mounted or installed were not permitted in the facility.
The findings include:
A physical plant inspection was conducted on March 15, 2012. It was observed during the inspection from approximately 9:50 A.M. to 10:00 A.M., that there were three portable space heaters located in the gym.
The findings were confirmed during an ongoing dialogue with the maintenance man on March 15, 2012 from approximately 9:50 A.M. to 10:00 A.M.
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Plan of Correction
The facility director has removed the 3 portable space heaters from the gym and the garage where they were stored as of 04/30/2012 and removed them from the facility property. The facility director will be responsible for making sure that portable space heaters are not permitted anywhere in the facility. |
705.9 (4) (i) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
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Observations
Based on a review of the facility's written procedures for staff and clients to follow in case of an emergency, the facility failed to provide written procedures for staff and clients to follow in case of an emergency for the evacuation and transfer of clients to a specific safe location for internal disasters.
The findings include:
The written procedures for staff and clients to follow in case of an emergency was viewed on March 15, 2012. The policy in the manual addresses external disasters. However, the policy does not give a specific safe location for internal disasters.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 9:00 A.M. to 3:30 P.M.
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Plan of Correction
The facility director has inserted a step in the emergency procedures that includes written procedures for the staff and clients to follow in case of an emergency for evacuation and transfer of clients to a specific location for internal disasters. The facility director will be responsible for ensuring that the written procedures remain in place at this facility. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on observations on March 15, 2012, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
The findings include:
A physical plant inspection was conducted on March 15, 2012. It was observed during the inspection from approximately 9:50 A.M. to 10:00 A.M., that one of the two exits at the facility's gym was sealed closed.
The findings were confirmed during an ongoing dialogue with the maintenance man on March 15, 2012 from approximately 9:50 A.M. to 10:00 A.M.
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Plan of Correction
The maintenance man unsealed the door and it is now an accessible way for entering or leaving the gym. The maintenance man will do monthly inspections to ensure that exits in the stairways, hallways, and exits are unobstructed so that this deficiency does not happen again. The facility director will oversee to make sure this happens. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on observations on March 15, 2012, the facility failed to clearly indicate exits by the use of signs.
The findings include:
A physical plant inspection was conducted on March 15, 2012. It was observed during the inspection from approximately 9:50 A.M. to 10:00 A.M., that the two exits in the gym did not have exit signs posted.
The findings were confirmed during an ongoing dialogue with the maintenance man on March 15, 2012 from approximately 9:50 A.M. to 10:00 A.M.
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Plan of Correction
The maintenance man has placed exit signs above each door in the gym. The maintenance man will do monthly inspections to ensure that exits signs are in place above each exit and that this deficiency does not happen again. The facility director wii check with the maintenance man each month to see that this occurs. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on observations on March 15, 2012, the facility failed to maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
The findings include:
A physical plant inspection was conducted on March 15, 2012. It was observed during the inspection from approximately 9:50 A.M. to 10:00 A.M., that the gym did not have a smoke detector.
The findings were confirmed during an ongoing dialogue with the maintenance man on March 15, 2012 from approximately 9:50 A.M. to 10:00 A.M.
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Plan of Correction
The maintenance man has installed a smoke detector in the ceiling of the gym and tested it to make sure it works.The maintenance man will do monthly inspections of all the locations where smoke detectors are installed on both floors and in the other areas where they are required to be operable and in place. He will also check them to be sure they are functional The facility director will oversee making sure this happens. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff starting at the facility.
The findings include:
On March 15, 2012, five personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not instruct staff in the use of the fire extinguisher upon staff starting at the facility in four of five personnel records reviewed, specifically, personnel records # 6, 7, 9, and 10.
Volunteer/support staff # 6 is a volunteer that works in clerical and started on January 23, 2012. Volunteer/support staff # 6 was due to complete fire extinguisher training upon starting at the facility. However, personnel record # 6 did not include documentation of fire extinguisher training as of March 15, 2012.
Volunteer/support staff # 7 is a volunteer that works as a night watchman and started on February 7, 2012. Volunteer/support staff # 7 was due to complete fire extinguisher training upon starting at the facility. However, volunteer/support staff # 7 did not complete fire extinguisher training until February 16, 2012.
Volunteer/support staff # 9 is a volunteer that works as a driver, cook, and monitor for dayroom and recreation and started on March 24, 2011. Volunteer/support staff # 9 was due to complete fire extinguisher training upon starting at the facility. However, volunteer/support staff # 9 did not complete fire extinguisher training until January 4, 2012.
Volunteer/support staff # 10 is a volunteer that works as a driver, cook, and monitor and started on July 31, 2011. Volunteer/support staff # 10 was due to complete fire extinguisher training upon starting at the facility. However, volunteer/support staff # 10 did not complete fire extinguisher training until January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
The facility director will make sure that all volunteers and staff are trained in the usage of fire extinguishers during the first week of their employment or service here. It will be documented by the facility director and then placed in their file during the first week of service. The facility director has ensured that volunteer #6 has successfully completed fire extinguisher training as of 4/25/2012. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies upon starting at the facility.
The findings include:
On March 15, 2012, five personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not ensure that all personnel on all on all shifts completed emergency training upon starting at the facility in four of five personnel records reviewed, specifically, personnel records # 6, 7, 9, and 10.
Volunteer/support staff # 6 is a volunteer that works in clerical and started on January 23, 2012. Volunteer/support staff # 6 was due to complete emergency training upon starting at the facility. However, personnel record # 6 did not include documentation of emergency training as of March 15, 2012.
Volunteer/support staff # 7 is a volunteer that works as a night watchman and started on February 7, 2012. Volunteer/support staff # 7 was due to complete emergency training upon starting at the facility. However, volunteer/support staff # 7 did not complete emergency training until February 16, 2012.
Volunteer/support staff # 9 is a volunteer that works as a driver, cook, and monitor for dayroom and recreation and started on March 24, 2011. Volunteer/support staff # 9 was due to complete emergency training upon starting at the facility. However, volunteer/support staff # 9 did not complete emergency training until January 4, 2012.
Volunteer/support staff # 10 is a volunteer that works as a driver, cook, and monitor and started on July 31, 2011. Volunteer/support staff # 10 was due to complete emergency training upon starting at the facility. However, volunteer/support staff # 10 did not complete emergency training until January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
The facility director will make certain that all new volunteers and staff are trained in Teen Challenge's emergency procedures training within their first week of service. The facility director has ensured that #6 volunteer has successfully completed emergency training as of 4/25/2012. |
709.32(c)(7) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(7) Medication errors and drug reactions.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to provide a written policy regarding medications used by clients that included drug reactions.
The findings include:
The facility's policy regarding medications used by clients was reviewed on March 14, 2012 and March 15, 2012. The policy in the manual addresses medication errors. However, the policy in the manual did not address drug reactions.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 9:00 A.M. to 3:30 P.M.
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Plan of Correction
The facility director has inserted a policy in the policy manual that addresses drug reactions and will present this policy to the board for approval on May 17th 2012. All staff and volunteers have been informed of this policy change and the facility director will ensure that this new policy remain in place at the facility once it is approved by the board. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Induction Intake and Admission 14B-6 Student Histories," states:
"Western PA Teen Challenge will follow the policies set down by the Training Center documenting Student Histories ie. Medical, drug or alcohol, personal, consent to treatment, physical examination, and psychosocial evaluation."
Also, the facility's policy titled: "Intake and Admission," states:
"Intake Interview
During their first week at the Center, all students will be scheduled for an initial intake interview with their counselor or an intake counselor. This interview consists of ... ....(6) Begin development of Psychosocial History ii) Subsequent intake sessions may be necessary for the completion of the psychosocial. This is to be completed within the first fifteen (15) business days of treatment."
On March 15, 2012 four client records requiring documentation of a medical history were reviewed. The facility did not document a medical history according to their policy and procedure in four of four records reviewed, specifically, client records # 1, 2, 3, and 4.
Client # 1 was admitted January 9, 2012. The medical history was due January 30, 2012. The medical history was completed; however, the medical history did not include a date of completion.
Client # 2 was admitted January 27, 2012. The medical history was due February 17, 2012. The medical history was completed; however, the medical history did not include a date of completion.
Client # 3 was admitted December 11, 2011. The medical history was due December 30, 2011. The medical history was completed; however, the medical history did not include a date of completion.
Client # 4 was admitted November 3, 2011. The medical history was due November 24, 2011. The medical history was completed; however, the medical history did not include a date of completion.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 3:00 P.M. to 3:15 P.M.
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Plan of Correction
The project director has inserted a line for the date to be written on the psychosocial histories which include the medical history beneath the place where the counselor signs his name. The project director will randomly screen counselor psychosocial histories each month to assure that they are completing them within l5 days of their entry into the program and that they are being dated. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug or alcohol history in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Induction Intake and Admission 14B-6 Student Histories," states:
"Western PA Teen Challenge will follow the policies set down by the Training Center documenting Student Histories ie. Medical, drug or alcohol, personal, consent to treatment, physical examination, and psychosocial evaluation."
Also, the facility's policy titled: "Intake and Admission," states:
"Intake Interview
During their first week at the Center, all students will be scheduled for an initial intake interview with their counselor or an intake counselor. This interview consists of ... ....(6) Begin development of Psychosocial History ii) Subsequent intake sessions may be necessary for the completion of the psychosocial. This is to be completed within the first fifteen (15) business days of treatment."
On March 15, 2012 four client records requiring documentation of a drug or alcohol were reviewed. The facility did not document a drug or alcohol history according to their policy and procedure in four of four records reviewed, specifically, client records # 1, 2, 3, and 4.
Client # 1 was admitted January 9, 2012. The drug or alcohol history was due January 30, 2012. The drug or alcohol history was completed; however, the drug or alcohol history did not include a date of completion.
Client # 2 was admitted January 27, 2012. The drug or alcohol history was due February 17, 2012. The drug or alcohol history was completed; however, the drug or alcohol history did not include a date of completion.
Client # 3 was admitted December 11, 2011. The drug or alcohol history was due December 30, 2011. The drug or alcohol history was completed; however, the drug or alcohol history did not include a date of completion.
Client # 4 was admitted November 3, 2011. The drug or alcohol history was due November 24, 2011. The drug or alcohol history was completed; however, the drug or alcohol history did not include a date of completion.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 3:00 P.M. to 3:15 P.M.
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Plan of Correction
The project director has inserted a line for the date to be written on the psychosocial histories which include the drug or alcohol history beneath the place where the counselor signs his name. The project director will randomly screen counselor psychosocial histories each month to assure that they are completing them within l5 days of their entry into the program and that they are being dated. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Induction Intake and Admission 14B-6 Student Histories," states:
"Western PA Teen Challenge will follow the policies set down by the Training Center documenting Student Histories ie. Medical, drug or alcohol, personal, consent to treatment, physical examination, and psychosocial evaluation."
Also, the facility's policy titled: "Intake and Admission," states:
"Intake Interview
During their first week at the Center, all students will be scheduled for an initial intake interview with their counselor or an intake counselor. This interview consists of ... ....(6) Begin development of Psychosocial History ii) Subsequent intake sessions may be necessary for the completion of the psychosocial. This is to be completed within the first fifteen (15) business days of treatment."
On March 15, 2012 four client records requiring documentation of a personal history were reviewed. The facility did not document a personal history according to their policy and procedure in four of four records reviewed, specifically, client records # 1, 2, 3, and 4.
Client # 1 was admitted January 9, 2012. The drug or alcohol history was due January 30, 2012. The personal history was completed; however, the personal history did not include a date of completion.
Client # 2 was admitted January 27, 2012. The personal history was due February 17, 2012. The personal history was completed; however, the personal history did not include a date of completion.
Client # 3 was admitted December 11, 2011. The personal history was due December 30, 2011. The personal history was completed; however, the personal history did not include a date of completion.
Client # 4 was admitted November 3, 2011. The personal history was due November 24, 2011. The personal history was completed; however, the personal history did not include a date of completion.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 3:00 P.M. to 3:15 P.M.
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Plan of Correction
The project director has inserted a line for the date to be written on the psychosocial histories which include the personal history beneath the place where the counselor signs his name. The project director will randomly screen counselor psychosocial histories each month to assure that they are completing them within l5 days of their entry into the program and that they are being dated. |
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, the facility failed to document a physical examination in with their policy and procedures and/or document a physical examination that included the physician's overall impression of the client.
The findings include:
The facility's policy titled: "Physical Examination," states:
"Prior to admission, the student shall receive a physical examination."
On March 15, 2012, four records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination according to their policy and procedures in one of four records reviewed, specifically, client record # 2. Also, the facility did not document a physical examination included the physician's overall impression of the client in three of four records reviewed, specifically, client records # 2, 3, and 4.
Client # 2 was admitted January 27, 2012. The physical examination was due prior to admission. The physical examination was completed; however, the physical examination did not include a date of completion and the physician's overall impression of the client.
Client # 3 was admitted December 11, 2011. The physical examination was completed July 1, 2011 but did not include the physician's overall impression of the client.
Client # 4 was admitted November 3, 2011. The physical examination was completed October 28, 2011 but did not include the physician's overall impression of the client.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
The facility director will inform his administrative assistant who does intake to do a better job of scrutinizing the physical exams before a student is admitted into the program. It will be the administrative assistant's responsibility to ensure that the physical exams of incoming clients are documented in accordance with this facility's policy and procedures.In the event that the date is missing or the overall impression is not filled out, the administrative assistant will be responsible to return the exam to the client, inform him of what is missing on the exam and tell the client he cannot be accepted into the program until this is completed properly. This communication has been made to the administrative assistant as of 3/28/2012 by the facility director. The facility director will ensure that the administrative assistant does everything that has been indicated in this poc. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in accordance with the facility's policy and procedures and document a psychosocial evaluation that included an assessment of the client's support systems, coping mechanisms, and/or attitude toward treatment.
The findings include:
The facility's policy on psychosocial evaluations indicates that the psychosocial evaluation is to be completed within the first fifteen business days of treatment.
On March 15, 2012, four client records requiring documentation of psychosocial evaluations were reviewed. The facility did not document a psychosocial evaluation according to their policy and procedures in four of four records reviewed, specifically, client records # 1, 2, 3, and 4. Also, the facility did not document a psychosocial evaluation that included an assessment of the client's support systems, coping mechanisms, and/or attitude toward treatment in four of four records reviewed, specifically, client records # 1, 2, 3, and 4.
Client # 1 was admitted January 9, 2012. The psychosocial evaluation was due January 27, 2012. The psychosocial evaluation was completed; however, the psychosocial evaluation did not have a date of completion. Also, the psychosocial evaluation did not include an evaluation of the client's coping mechanisms and attitude toward treatment.
Client # 2 was admitted January 27, 2012. The psychosocial evaluation was due February 17, 2012. The psychosocial evaluation was completed; however, the psychosocial evaluation did not have a date of completion. Also, the psychosocial evaluation did not include an evaluation of the client's support system, coping mechanisms, and attitude toward treatment.
Client # 3 was admitted December 11, 2011. The psychosocial evaluation was due December 30, 2011. The psychosocial evaluation was completed; however, the psychosocial evaluation did not have a date of completion. Also, the psychosocial evaluation did not include an evaluation of the client's support system, coping mechanisms, and attitude toward treatment.
Client # 4 was admitted November 3, 2011. The psychosocial evaluation was due November 24, 2011. The psychosocial evaluation was completed; however, the psychosocial evaluation did not have a date of completion. Also, the psychosocial evaluation did not include an evaluation of the client's support system.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
The facility director has gone over the Regulation (with the counselors) pertaining to evaluations and their need to include client support systems, coping mechanisms and attitude toward treatment. The facility director has also placed a line under the signature place on the psychosocial evaluations used by the counselors to date their histories upon their completion within 15 days of their entry into the program.The facility driector will randomly screen the counselor files on a monthly basis to assure that the psychosocial evaluations are being done correctly and that they are being dated. |
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
Based on a review of client records, the facility failed to comply with treatment and rehabilitation services relating to documentation of an individual treatment and rehabilitation plan.
The findings include:
The facility's policy titled: "Comprehensive Treatment Plan," states:
"An Individualized treatment and rehabilitation plan (Comprehensive Treatment Plan) shall be developed for each student within the first fifteen (15) business days of admission of treatment."
On March 15, 2012, four client records requiring documentation of an individualized treatment and rehabilitation plan were reviewed. The facility did not document an individualized treatment and rehabilitation plan upon completion of the psychosocial history and psychosocial evaluation in four of four records reviewed, specifically, client records # 1, 2, 3, and 4.
Client # 1 was admitted January 9, 2012. The individual treatment and rehabilitation was due upon completion of the psychosocial history and psychosocial evaluation by January 27, 2012. The individual treatment and rehabilitation plan was completed on January 23, 2012. However, the psychosocial history and psychosocial evaluation in client record # 1 did not include a date of completion.
Client # 2 was admitted January 27, 2012. The individual treatment and rehabilitation was due upon completion of the psychosocial history and psychosocial evaluation by February 17, 2012. The individual treatment and rehabilitation plan was completed on February 10, 2012. However, the psychosocial history and psychosocial evaluation in client record # 2 did not include a date of completion.
Client # 3 was admitted December 11, 2011. The individual treatment and rehabilitation was due upon completion of the psychosocial history and psychosocial evaluation by December 30, 2011. The individual treatment and rehabilitation plan was completed on December 23, 2011. However, the psychosocial history and psychosocial evaluation in client record # 3 did not include a date of completion.
Client # 4 was admitted November 3, 2011. The individual treatment and rehabilitation was due upon completion of the psychosocial history and psychosocial evaluation by November 24, 2011. The individual treatment and rehabilitation plan was completed on November 23, 2011. However, the psychosocial history and psychosocial evaluation in client record # 4 did not include a date of completion.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
The facility director has informed the counselors that they need to have their treatment plans completed and dated within 15 days of the client's admission to treatment. The facility director has inserted a line for the date to be placed on their treatment plans next to their signature. Facility director will randomly screen their treatment plans monthly to assure that they are being dated and completed within 15 days of clients entrance into the program. The facility director will be responsible for monitoring the treatment and rehabilitation plans to ensure that they are completed and signed within 15 days of the completions of the client psychosocial and history evaluations. |
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 document a treatment plan update and/or subsequent treatment plan updates in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Treatment Plan Update," states:
"The Treatment Plan Update shall be written within thirty days of the Comprehensive Treatment Plan."
On March 15, 2012, four client records requiring documentation of a treatment plan update were reviewed and two client records requiring documentation of a subsequent treatment plan update were reviewed. The facility did not document a treatment plan update according to their policy and procedures in four of four records reviewed, specifically, client records # 1, 2, 3, and 4. The facility also did not document a subsequent treatment plan update according to their policy and procedures in two of two records reviewed, specifically, client records # 3 and 4.
Client # 1 was admitted January 9, 2012. The comprehensive treatment plan was completed January 23, 2012 and the treatment plan update was due within thirty days from the completion of the comprehensive treatment plan by February 22, 2012. The treatment plan update was completed; however, the treatment plan update did not include a date of completion.
Client # 2 was admitted January 27, 2012. The comprehensive treatment plan was completed February 10, 2012 and the treatment plan update was due within thirty days from the completion of the comprehensive treatment plan by March 11, 2012. The treatment plan update was completed; however, the treatment plan update did not include a date of completion.
Client # 3 was admitted December 11, 2011. The comprehensive treatment plan was completed December 23, 2011 and the treatment plan update was due within thirty days from the completion of the comprehensive treatment plan by January 22, 2012. Also, subsequent treatment plan updates were due by February 22, 2012 and March 22, 2012. The treatment plan update and subsequent treatment plans were completed; however, the treatment plan update and subsequent treatment plan updates did not include a date of completion.
Client # 4 was admitted November 3, 2011. The comprehensive treatment plan was completed November 23, 2011 and the treatment plan update was due within thirty days from the completion of the comprehensive treatment plan by December 23, 2012. Also, subsequent treatment plan updates were due by February 22, 2012 and March 23, 2012. The treatment plan update and subsequent treatment plans were completed; however, the treatment plan update and subsequent treatment plan updates did not include a date of completion.
The findings were confirmed during an ongoing dialogue with the facility director on March 15, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
The facility director has placed a line with a date under it by the signature line on the treatment plan updates used by the counselors to date their treatment updates. The facility director will randomly screen counselor files and check their treatment plan updates to assure that they are dating them. Dates of completion on the client treatment plan updates that were cited during the inspection have been documented by the facility director. The facility director will randomly screen the counselor's treatment plan updates to ensure that they are being completed on time and in accordance with the facility's policy and procedures. |
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 document follow-up information in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "17B Western PA Project Management Services 17 B-5 Follow-UP," states:
"The Head Counselor is responsible for the follow-up of each client. Contact will be established via telephone, letter, or other methods. Initial contact shall be established within seven (7) days of termination of services. Said contact shall be documented in the student ' s progress notes."
On March 15, 2012 three client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information according to their policy and procedures in two of three records reviewed, specifically, client records # 5 and 7.
Client # 5 was admitted March 26, 2011 and was discharged July 29, 2011. The follow-up information was due August 5, 2011. The follow-up information was completed; however, the follow-up information did not include a date of completion.
Client # 7 was admitted September 2011 and was discharged January 27, 2012. The follow-up information was due January 3, 2012. The follow-up information was completed; however, the follow-up information did not include a date of completion.
The findings were confirmed during an ongoing dialogue with the facility director and counselor assistant on March 15, 2012 from approximately 3:00 P.M. to 3:15 P.M.
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Plan of Correction
The project director has inserted a date line on the followup form to assure that it be dated and followup is done withinh 7 days of a client leaving the program. The project director will include checking followups randomly on a monthly basis. |