INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 3, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, Teen Challenge Training Center 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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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based upon a physical plant plant inspection the facility failed to employ support staff in sufficient numbers to insure the efficient and safe operation of all of the services provided by the project.
The findings include:
A physical plant inspection of the facility and grounds was conducted along with the Director of Student Services at approximately 3:00 PM. Durr the physical plant inspection the Licensing Specialists specifically requested to inspect the "Blue House" referenced in the complaint. Upon inspecting the "Blue House" the rear basement was found to have an open doorway with the door lying on the floor. In addition, there was a pile of ashes observed on the floor near the interior stair of the building.
The Director of Student Services stated that there were a couple of incidences in the past few months where local teenagers had broken into the house.
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Plan of Correction
First, we have contracted with a local contractor to assist us with repairs to facilities on campus. Secondly, we have hired a part-time maintenance person. These additions will ensure that our facilities are kept up and maintained in an acceptable manner. We have also instituted a computerized work order recording system, where individuals can submit maintenance work order request directly to the maintenance department, so that areas of concern can be addressed and repaired. To prevent this from reoccurring, the facility manager and chief operating officer will ensure that the maintenance department has sufficient staff and or contractors to handle repairs to ensure that all facilities are kept up.
In addition, we will immediately begin having our front desk staff make rounds and inspect all facilities that are outside the boundaries of the TCTC main campus which students are restricted to, but within the property of TCTC, to ensure that no unauthorized persons gain access to any of our facilities. These rounds will be conducted once weekly on Saturdays by the front desk staff. They will also ensure all exterior doors have working locks installed on them and that any broken windows are repaired or boarded up. These rounds will be documented on our front desk duty shift sheets with time inspected and any issues that were discovered. To prevent this from reoccurring, The Program Manager will ensure that rounds are conducted in accordance with above statement and that any findings are given to the facility manager for correction. If there are any break-ins discovered, the local police will be contacted.
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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.
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Observations
Based upon a physical plant plant inspection the facility failed to 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 findings include:
A physical plant inspection of the facility and grounds was conducted along with the Director of Student Services at approximately 3:00 PM. Durr the physical plant inspection the Licensing Specialists specifically requested to inspect the "Blue House" referenced in the complaint. Upon inspecting the "Blue House" the rear basement was found to have an open doorway with the door lying on the floor. In addition, there was a pile of ashes observed on the floor near the interior stair of the building.
The Director of Student Services stated that there were a couple of incidences in the past few months where local teenagers had broken into the house.
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Plan of Correction
On February 21, 2012, a request was submitted to seal off entrance of said building. The Basement was cleaned. It was confirmed completed by the Assistant Facility Manager. As completed on February 23, 2012
To prevent this from reoccurring the Facility/Maintenance Director shall assure that all buildings are clean, safe and in good repair. All residents of Teen Challenge properties will keep track of any deficiencies of their personal housing and work area, and communicate through the electronic work order system these deficiencies to the Facilities Department.
In addition, we will immediately begin having our front desk staff make rounds and inspect all facilities that are outside the boundaries of the TCTC main campus which students are restricted to, but within the property of TCTC, to ensure that no unauthorized persons gain access to any of our facilities. These rounds will be conducted once weekly on Saturdays. They will also ensure all exterior doors have working locks installed on them and that any broken windows are repaired or boarded up. These rounds will be documented on our front desk duty shift sheets with time inspected and any issues that were discovered. To prevent this from reoccurring, The Program Manager will ensure that rounds are conducted in accordance with above statement and that any findings are given to the facility manager for correction. If there are any break-ins discovered, the local police will be contacted.
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709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based upon the inability of the facility to produce the requested client record at the time of the inspection, the facility failed to develop a system that allowed for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
The findings include:
A request to review the facility census consisting of active and inactive D & A clients was made at 9:55 AM on January 3, 2012. Upon receiving the list, records were requested to be presented for review. It took the facility 30 - 45 minutes to produce the majority of the records requested; however, client #1's record was not able to be produced a the time of the inspection. It was not until the inspection was over and the Licensing Specialists were preparing to leave, that the Director of Student Services stated that they could now provide the client record.
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Plan of Correction
The following procedure is to be followed in the event that the Clinical supervisor is absent for any extended period of time.
If the absence is planned (i.e. vacation, medical, etc.), then arrangements will be made to ensure that the counseling phone and any keys that may be necessary are transferred directly to the person designated to be placed in charge during his absence. These arrangements will be made in advance and the counselor designated will receive these items by 5 oˇ¦clock p.m. on the last day that the Clinical Supervisor is scheduled to work before his leave.
In the event of an unforeseen situation (i.e. medical, family emergency, etc.), then the clinical supervisor will be responsible to ensure that the person designated to fill in for him in his absence has the above mentioned items in order to perform the duties necessary in the supervisors absence. The clinical supervisor will need to ensure that the keys are dropped off with the individual filling in, if he has to leave work suddenly, or turned over to the Student Services Director to be handed to the designated individual the following work day.
The duties and limitations of the person filling in for the clinical supervisor are as follows:
?± To oversee the counseling department and field any questions or concerns that may arise pertaining to the job.
?± To collect employee time cards at the end of every week and ensure that they are properly filled in and ready to be submitted for the Student Services directorˇ¦s signature. (If the Student Services Director is out, then it is the responsibility of the interim clinical supervisor to sign the supervisor signature and submit them to the finance department)
?± To conduct weekly counselorˇ¦s meetings covering any vital information that needs to be communicated
?± To process and submit any Graduate Application forms that may need to be completed
To prevent this from reoccurring the Student Services Director shall assure procedures are followed hereafter.
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709.17(a)(8) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(8) Mistreating or abusing individuals cared for or treated by the facility.
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Observations
Based upon a review of the facility's procedures outlined on the form titled: "Teen Challenge Training Center Sexual Harassment", one personnel record and a facility incident file, the facility failed to follow their procedure to determine if mistreatment or abuse occurred.
The findings include:
One personnel record and a facility incident file were reviewed on January 3, 2012.
Documentation contained in the personnel file included the following item:
A Service Exit Form for the employee that was dated May 12, 2011. The form was signed and dated by the employee's Supervisor and the Director of Human Resources. However, the employee did not sign or date the form. A hand written note at the bottom of the form stated, " redacted name would not sign form."
The Service Exit Form identified that the individual's employment ended on May 11, 2011, and the following information was included on the form.
Reason for Departure: "Resignation"- a hand written note said, "will send resignation."
Reason for Dismissal: "Unacceptable Conduct"
Your understanding of employee's departure: "Counselor placed his hands on students (sic) legs."
After reviewing the Service Exit Form, Licensing Staff requested to see any incident reports or documentation related to the "Unacceptable Conduct" identified on the Service Exit Form.
The Director of Student Services provided a facility incident file that contained the following documentation:
1) A form with the heading "Teen Challenge Training Center Grievance." The form listed the date of the grievance as May 10, 2011. The form was signed and dated by a student from the facility on May 12, 2011. Included with the grievance form was a two page (both sides) hand written statement from the student dated May 8, 2011, alleging inappropriate contact/questions from the student's primary counselor.
2) An Incident Report completed by the Clinical Supervisor dated May 10, 2011 that noted that the counselor admitted to placing both hands on the student's legs and asking the student certain questions; however, the counselor stated that it was not sexual in nature. The Clinical Supervisor also noted in the incident report that this was the second time a student reported inappropriate touch by this counselor. When asked about the first incident, the Director of Student Services stated that this occurred months before and involved a different student whereby the counselor awoke the student by touching his shoulder. The facility does not permit physical contact with students. (The facility was unable to produce a copy of a facility incident file for this occurrence).
3) A copy of a form titled: "Teen Challenge Training Center Sexual Harassment" with a subtitle "Procedures" which outlined the steps to be taken when an accuser makes a claim of sexual harassment. The subsections titled Finding and Closing state the following:
Finding: Once all interviews are done, a decision must be made. Taking all the information collected: Did harassment occur based on the following: "Harassment includes verbal, physical, and visual conduct that creates an intimidating, offensive or hostile working environment that interferes with work performance. As an example, sexual harassment
(both overt and subtle) is a form of employee misconduct that is demeaning to another person, undermines the integrity of the employment relationship, and is strictly prohibited."
Closing: Final report should include: What was determined of the findings. Action taken. Preventative steps that will follow. All documents involved in this investigation must be kept together in a separate file from each employees. (sic) Files should be kept separated and in a locked file.
5) A copy of a form titled: "Sexual & Other Unlawful Harassment Report" dated May 11, 2011, indicated the following:
Findings: INVESTIGATION STOPPED BY RESIGNATION LETTER
Closing: Determination of findings: "Investigation was stopped due to the receipt of resignation of (name redacted)".
Action taken: "Processed the resignation letter"
6) A copy of a letter, dated May 12, 2011, that was sent to the employee confirming that his letter of resignation was accepted as of May 11, 2011. The facility did not complete the investigation as outlined in the facility's procedures. The facility stopped the investigation upon receipt of the resignation letter. No decision was rendered as to whether or not harassment actually occurred. In addition, the facility failed to identify what preventative steps would be taken in the future.
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Plan of Correction
Effective immediately we will re-open the investigation and complete it to the best of our ability. We will start by obtaining current mailing addresses for each individual involved. We will send the letters to each party via certified mail no later than Friday
April 20, 2012
To prevent this from occurring in the future the facility's Human Resource department will continue to follow the policy & procedure that is in place regardless if the accuser or harasser is still available. The investigation will be completed to the best of our ability. Each party will be notified of the results.
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