INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 17, 2017 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
A physical plant inspection was conducted on August 17, 2017. Based on this inspection, the facility failed to clean and disinfect food preparation areas following each prepared meal.
During the physical plant inspection, the food preparation area of the kitchen was observed to be dirty. Specifically, there was dirt, food particles and debris under preparation areas and shelving units in the kitchen. A rancid odor was also prominent in the food preparation area.
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Plan of Correction
Shelves, floors and underneath food storage/prep areas were immediately cleaned upon the completion of the inspection by DDAP on August 17, 2017. The staff and students now include these areas in twice daily cleaning practices to ensure all food debris and waste is swept and disposed of. Shift supervisors utilize check off sheets to ensure these areas are taken care of as part of their supervisory shift responsibilities. Files are maintained for review by HR Director.
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
A physical plant inspection was conducted on August 17, 2017. Based on this inspection, the facility failed to ensure that it was free of rodent infestation.
During the physical plant inspection, rodent excrement was observed in several locations in the dining room.
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Plan of Correction
PP091- At the time of inspection the inspectors were provided with evidence to show the center by is serviced by a pest control company on a monthly basis. On August 18, 2017 the pest control company was called to discuss the finding of the inspection. The contractor agreed to set up more baits and traps for vermin upon his next scheduled visit for September. This was accomplished during the September visit as planned. The contractor checks these additional traps on a monthly basis along with the other traps set throughout the property. The Operations Coordinator at PAATC is responsible for working with the pest control contractor on a monthly basis to monitor traps and ensure appropriate services are being utilized to combat rodent activity.
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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
A review of client records was conducted on August 17, 2017. Based on this review, the facility failed to develop an individual treatment and rehabilitation plan with a client.
Client #1's treatment plan dated June 07, 2017 did not include a client or clinician signature.
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Plan of Correction
A review of client records was conducted on August 17, 2017. Based on this review, the facility failed to maintain a complete client record in the 3 areas of; Treatment Planning (709.52(a) 2), Aftercare Planning (709.53(a)(9), and Discharge Summary (709.53(a)(10). At this time we had a counselor resign who was not able to keep up on her records. In October we hired three additional primary counselors to assist with the growing census and need for case management. On 8/24/2017, after the inspection the treatment team met for the weekly team meeting and discussed the proper way to complete a treatment plan, aftercare plan, and discharge summary. As a result of these findings Teen Challenge Training's Center clinical supervisor conducted an internal audit and review of all client records. This was completed on 9/21/2017 when at this time all of the records were brought into compliance. At this time client record compliance was added to the agenda for the weekly team meeting and discussed an ongoing plan to keep the record in compliance and conduct regular internal auditing. The program director and clinical supervisor met for a training (11/8/2017) to review the proper way to conduct internal audits. At this time we developed a chart audit checklist as a tool to make sure all required documents are the client record. We then developed a plan to have the clinical supervisor conduct weekly audits for half of the counselors. Now our auditing procedures auditing of 3 client records from all of our 7 counselors 2x per month. The results of these audits are discussed at our weekly meetings. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
A review of client records was conducted on August 17, 2017. Based on this review, the facility failed to develop an individual treatment and rehabilitation plan that includes written documentation of type and frequency of treatment and rehabilitation services.
Client # 1's treatment plan dated June 07, 2017 did not include type and frequency of treatment and rehabilitation services.
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Plan of Correction
A review of client records was conducted on August 17, 2017. Based on this review, the facility failed to maintain a complete client record in the 3 areas of; Treatment Planning (709.52(a) 2), Aftercare Planning (709.53(a)(9), and Discharge Summary (709.53(a)(10). At this time we had a counselor resign who was not able to keep up on her records. In October we hired three additional primary counselors to assist with the growing census and need for case management. On 8/24/2017, after the inspection the treatment team met for the weekly team meeting and discussed the proper way to complete a treatment plan, aftercare plan, and discharge summary. As a result of these findings Teen Challenge Training's Center clinical supervisor conducted an internal audit and review of all client records. This was completed on 9/21/2017 when at this time all of the records were brought into compliance. At this time client record compliance was added to the agenda for the weekly team meeting and discussed an ongoing plan to keep the record in compliance and conduct regular internal auditing. The program director and clinical supervisor met for a training (11/8/2017) to review the proper way to conduct internal audits. At this time we developed a chart audit checklist as a tool to make sure all required documents are the client record. We then developed a plan to have the clinical supervisor conduct weekly audits for half of the counselors. Now our auditing procedures auditing of 3 client records from all of our 7 counselors 2x per month. The results of these audits are discussed at our weekly meetings. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
A review of client records was conducted on August 17, 2017. Based on this review, the facility failed to maintain a complete client record on an individual which includes information relate to the client's involvement with the project. This shall include, but not be limited to an aftercare plan.
Client # 1's file did not include an aftercare plan. Client # 1 was successfully discharged on June 23, 2017.
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Plan of Correction
A review of client records was conducted on August 17, 2017. Based on this review, the facility failed to maintain a complete client record in the 3 areas of; Treatment Planning (709.52(a) 2), Aftercare Planning (709.53(a)(9), and Discharge Summary (709.53(a)(10). At this time we had a counselor resign who was not able to keep up on her records. In October we hired three additional primary counselors to assist with the growing census and need for case management. On 8/24/2017, after the inspection the treatment team met for the weekly team meeting and discussed the proper way to complete a treatment plan, aftercare plan, and discharge summary. As a result of these findings Teen Challenge Training's Center clinical supervisor conducted an internal audit and review of all client records. This was completed on 9/21/2017 when at this time all of the records were brought into compliance. At this time client record compliance was added to the agenda for the weekly team meeting and discussed an ongoing plan to keep the record in compliance and conduct regular internal auditing. The program director and clinical supervisor met for a training (11/8/2017) to review the proper way to conduct internal audits. At this time we developed a chart audit checklist as a tool to make sure all required documents are the client record. We then developed a plan to have the clinical supervisor conduct weekly audits for half of the counselors. Now our auditing procedures auditing of 3 client records from all of our 7 counselors 2x per month. The results of these audits are discussed at our weekly meetings. |
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
A review of client records was conducted on August 17, 2017. Based on this review, the facility failed to maintain a complete client record on an individual which includes information relate to the client's involvement with the project. This shall include, but not be limited to a discharge summary.
Client # 1's file did not include a discharge summary. Client # 1 was successfully discharged on June 23, 2017.
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Plan of Correction
A review of client records was conducted on August 17, 2017. Based on this review, the facility failed to maintain a complete client record in the 3 areas of; Treatment Planning (709.52(a) 2), Aftercare Planning (709.53(a)(9), and Discharge Summary (709.53(a)(10). At this time we had a counselor resign who was not able to keep up on her records. In October we hired three additional primary counselors to assist with the growing census and need for case management. On 8/24/2017, after the inspection the treatment team met for the weekly team meeting and discussed the proper way to complete a treatment plan, aftercare plan, and discharge summary. As a result of these findings Teen Challenge Training's Center clinical supervisor conducted an internal audit and review of all client records. This was completed on 9/21/2017 when at this time all of the records were brought into compliance. At this time client record compliance was added to the agenda for the weekly team meeting and discussed an ongoing plan to keep the record in compliance and conduct regular internal auditing. The program director and clinical supervisor met for a training (11/8/2017) to review the proper way to conduct internal audits. At this time we developed a chart audit checklist as a tool to make sure all required documents are the client record. We then developed a plan to have the clinical supervisor conduct weekly audits for half of the counselors. Now our auditing procedures auditing of 3 client records from all of our 7 counselors 2x per month. The results of these audits are discussed at our weekly meetings. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
A physical plant inspection was conducted on August 17, 2017. Based on this inspection, the facility failed to store food stuff properly.
During the physical plant inspection of the kitchen, several food items were identified in the pantry that had surpassed their expiration date.
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Plan of Correction
L1823- All expired items found in the pantry were immediately disposed of on August 18, 2017. Leadership met with the food services team on August 18, 2017 to discuss infractions and develop a plan of correction. As a result, the center has reduced contracts with food banks and increased food spending budget. All items purchased are within expiration. The center has changed leadership in food services and shift supervisors are responsible for having trained interns to monitor food pantry shelves to ensure items are used prior to expiration. |