INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12-13, 2014 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 the review of administrative documents, the facility failed to provide an evaluation of the overall training plan for 2013. The facility also failed to demonstrate that it had a mechanism in place to collect feedback from employees for trainings completed in 2013.
The findings include:
A review of administrative documentation was conducted from February 12-13, 2014. The facility failed to provide an evaluation of the overall training plan for 2013. The facility also failed to demonstrate that it had a mechanism in place to collect feedback from employees for trainings completed in 2013.
The facility director confirmed the findings.
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Plan of Correction
An evaluation sheet is to be distributed to staff by the Administrative Assistanted for evaluation of the overall training plan for the previous year and will be collected within a week by the Administrative Assistant. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of at least 12 clock hours of annual training for facility directors in one of one personnel records.
The findings include:
The facility training year is from January 1 through December 31.
One personnel record pertaining to the facility director was reviewed on February 12-13, 2014. The facility failed to document 12 clock hours of annual training for 2013 in personnel record # 1.
Employee # 1 was hired as the facility director on April 1, 2012. The facility failed to ensure that employee # 1 completed 12 clock hours of annual training for the 2013 training year. Record # 1 did not contain documentation of any training hours for 2013.
The facility director confirmed the findings.
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Plan of Correction
The Lead Counselor will be responsible for scheduling and collecting documentation of training hours completed for employees. Documentation will be given to the Administrative Assitant to be placed in the employee file. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records.
The findings include:
The facility training year is from January 1st through December 31st.
Two counselor personnel records were reviewed on February 12-13, 2014. The facility failed to document 25 clock hours of annual training for 2013 in personnel record # 3.
Employee # 3 was hired as a counselor on April 27, 2009. The facility failed to ensure that employee # 3 completed 25 clock hours of annual training for the 2013 training year. Record # 3 did not contain documentation of any training hours for 2013.
The facility director confirmed the findings.
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Plan of Correction
The Lead Counselor will be responsible for scheduling and collecting documentation of training hours completed for employees. Documentation will be given to the Administrative Assitant to be placed in the employee file. |
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
Based on a review of the facility's fire drill log, the facility failed to prepare alternate exits during fire drills conducted in 10 of 11 months reviewed.
The findings include:
The facility's fire drill log for the timeframe of March 2013 through January 2014 was reviewed on February 12, 2014. Based on documentation contained in the fire drill log, the facility failed to prepare alternate exits during the months of April, May, June, July, August, September, October, November and December 2013, and January 2014. Instead, the facility prepared and utilized the same four exits during the months referenced above.
The facility director confirmed the findings.
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Plan of Correction
The Facility Director will conduct fire drills in such a way that alternate exits can be utilized and documented in the fire drill log. Fire drills will have to be conducted not only at various times of the day, but during various activities so that the nearest available exit varies. To ensure that there is no reoccurance, staff will be present to direct clients to the proper exit, which will be different from the previous month. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on the review of client records, the facility failed to document a complete client record on each individual, to include an aftercare plan and follow-up information, in two of six client records.
The findings include:
As per facility policy, the facility is required to document an aftercare plan, prior to discharge, for clients who successfully complete the program. The facility is also required to document follow-up information within 30 days of a client's discharge.
Six client records were reviewed on February 12-13, 2014. The facility failed to document a complete record, to include aftercare plans and follow-up information, in client records # 5 and # 6.
Client # 5 was admitted to treatment on July 15, 2013 and successfully discharged on October 22, 2013. The facility failed to document an aftercare plan for client # 5 as of the date of inspection. The facility also failed to document follow-up information that was due by November 22, 2013.
Client # 6 was admitted to treatment on May 15, 2013 and successfully discharged on August 30, 2013. The facility failed to document an aftercare plan for client # 6 as of the date of inspection. The facility also failed to document follow-up information that was due by September 30, 2013.
The facility director confirmed the findings.
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Plan of Correction
There is a form that this facility uses to document the aftercare plan, which states that the client will transfer to the second phase at another facility. The Lead Counselor will be responsible for instructing the Counselors to document the aftercare plan. The Lead Counselor will also be responsible for conducting a monthly review of random files to ensure non-reoccurrance.
For follow-up information, the Lead Counselor will generate a form for documentation. Each Counselor will be responsible for making contact with the client within 30 days of transfer to the second phase and make a record of contact using the form generated by the Lead Counselor. The Lead Counselor will also be responsible for conducting a monthly review of random files to ensure non-reoccurrance. |
709.54(a)(1) LICENSURE Purchasing food/equipment
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:
(1) Purchasing of food and equipment.
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Observations
Based on the physical plant inspection, the facility failed to ensure that outdated food items were disposed of and were not being stored within the facility.
The findings include:
The physical plant inspection was conducted on February 13, 2014. The following items had expired dates but were being stored within the facility.
- Six cartons of beef soup broth had expiration dates from 2008.
- Six cartons of chicken soup broth has expiration dates from 2012.
- Two boxes of pasta were observed with expiration dates from 2012.
The facility director confirmed the findings.
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Plan of Correction
The Kitchen Supervisor will maintain and update an inventory of food items on a weekly basis. At the time of update and when new food items are brought into the storage area, older items will be rotated to the front for immediate use. The Kitchen Supervisor will also check the expiration dates at the time of rotation and discard any items that are out of date. |