INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2-3, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection the facility failed to store all trash, garbage, and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on February 2, 2015 at approximately 2 pm. The trash cans in the kitchen were not covered with lids.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
Trash can lids were located and put in place. Lids were attached to trash cans using a short chain to ensure that all trash cans will have a lid at all times. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 findings include:
A physical plant inspection was conducted on February 2, 2015. At approximately 2:30 p.m. the water temperature was tested in the bathroom in two different sinks. The readings were 128 and 140
The findings were reviewed with staff during the licensing inspection.
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Plan of Correction
A broken cold water mixing valve was located and replaced. This repair will ensure that sufficient cold water is routed to the hot water faucets in the facility to ensure that hot water does not exceed 120 degrees. Temperature checks were added to the monthly safety checklist completed by the facilities department. |
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 a physical plant inspection the facility failed to prohibit facility heaters that are not permanently or installed.
The findings include:
A physical plant inspection was conducted February 2, 2015 at approximately 2 pm. A space heater was observed in a counseling office.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
Employee at fault was identified and counseled by his direct supervisor on the policy regarding space heaters in the facility. Space heater was removed from the facility.
All counseling staff was reminded of the facility policy that there shall be no heaters that are not permanently attached. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection the facility failed to ensure all fire extinguishers are inspected and approved annually.
The findings include:
A physical plant inspection was conducted on February 2, 2015. In the area outside of the counselors office there was a fire extinguisher tagged with an inspection date of March 2013.
The findings were discussed with staff during the licensing process.
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Plan of Correction
Fire Extinguisher was replaced with an extinguisher that was inspected and approved within the past 12 months.
Teen Challenge Training Center Director of Facilities added specific extinguisher location to monthly safety checklist. Director of Facilities and Program Manager will ensure that monthly checks are completed. |
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 provide a complete client record on each individual in five of ten client records.
The findings include:
Ten client records were reviewed on February 2-3, 2015. Ten client records were reviewed for the inpatient non-hospital - residential treatment activity. The facility failed to provide a complete client record for records #2, 7, 8, 9, and 10.
Client #2 was admitted to treatment on May 14, 2014 and was discharged on June 27, 2014. Record #2 did not have documentation of an individual treatment plan or progress notes for each record of service.
Client #7 was admitted to treatment on October 10, 2014 and was still active in treatment at the time of the inspection. Record #7 did not have documentation of an individual treatment plan.
Client #8 was admitted to treatment on July 1, 2014 and was discharged on August 29, 2014. Record #8 did not have documentation of an individual treatment plan or a case consultation.
Client #9 was admitted to treatment on July 30, 2014, and was discharged on September 27, 2014. Record #9 did not have documentation of an individual treatment plan or a case consultation.
Client #10 was admitted to treatment on November 7, 2014, and it was unclear if the client was still active in treatment at the time of the inspection. Record #10 did not have documentation of an individual treatment plan, progress notes, or records of service.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Each deficiency was remedied. All current Drug and Alcohol Program files were reviewed by the clinical supervisor.
The clinical supervisor increased random file reviews for students in their Drug and Alcohol phase of the program.
Each individual counselor was counseled on the required documents that need to be in each clients file. |