INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2-4, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to document that each counselor met the educational and experiential requirements for the position.
Staff #6 was hired in a non-clinical position on June 29, 2017 and was promoted to counselor on May 1, 2018. Staff #6 holds a BA in Psychology which meets the educational requirement; however, staff #6 does not have at least one year of clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All future counselors will be hired following the education and experience requirements set up by DDAP. The director of Human Resources will ensure full compliance with this regulation. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The facility failed to ventilate toilet and wash rooms by exhaust fan or window.
A physical plant inspection was conducted on April 3, 2019. At the time of the inspection, the restroom in the admissions office was observed to not have an exhaust fan or window.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A ventilation fan will be installed in the Admissions Office Bathroom by May 17, 2019. The director of operations will be responsible for ensuring this correction and that we remain in full compliance. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The facility failed to develop written policy and procedures regarding the administration of medication that was in compliance with Pennsylvania law.
The policy and procedure documented by the facility states that certified nusing assistants and certified medical assistants may administer medications.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
policy will be updated to reflect that medication distribution in the short-term program will be done via supervised patient self-administration and monitored by Clinical Aids, certified nursing assistants and certified medical assistants. Upon the policy update the Short Term staff will be trained for observing and recording medication self-administration. Short Term Program staff will train and review the policy update by June 1, 2019.The clinical program director will ensure completion of this update and ongoing compliance. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to document that a narcotic treatment physician made a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug.
Patient #1 was admitted to detox on March 29, 2019 and was examined by a CRNP that same day. The CRNP, not the narcotic treatment physician, documented the face to face assessment and opiate dependence and ordered the buprenorphine taper.
Patient #2 was admitted to detox on March 28, 2019 and was examined by a CRNP that same day. The CRNP, not the narcotic treatment physician, documented the face to face assessment and opiate dependence and ordered the buprenorphine taper.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual will be updated to reflect that the physician will see a patient face to face in our detox program. The physician has also applied for a face to face waiver with the Department of Drug and Alcohol Program and SAMSHA. Once we receive the waiver then the policy will be adjusted to include consult with the CRNP after the CRNP has completed a face to face. Review of the policy and ongoing adherence to the regulation will be completed by the medical director. All policies and policy reviews will be completed by June 1, 2019. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
The facility failed to document policies and procedures regarding verbal medication orders that are in compliance with Federal and State statutes and regulations.
A review of the policy and procedure manual indicates that certified nurse practitioner or physician assistant may give a verbal, written or telephone order for buprenorphine. This is not permitted for facilities with a Certificate of Approval.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy will be updated to reflect the state and federal regulations 715 identifying that only the narcotic treatment physician may give verbal, written or telephone order. The CRNPs and narcotic treatment physician will review the policy update by June 1, 2019. The medical director will ensure that this policy is updated and adhered to. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility failed to document that a narcotic treatment physician determined the patient's initial and subsequent dose and schedule. In addition, each medication order and dosage change was not written and signed by the narcotic treatment physician.
Patient #1 was admitted to detox on March 29, 2019 and was examined by a CRNP that same day. The CRNP, not the narcotic treatment physician, documented the face to face assessment, opiate dependence and wrote the order for the buprenorphine taper.
Patient #2 was admitted to detox on March 28, 2019 and was examined by a CRNP that same day. The CRNP, not the narcotic treatment physician, documented the face to face assessment, opiate dependence and wrote the order for the buprenorphine taper.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual will be updated to reflect that the physician will see a patient face to face in our detox program.The physician will also be responsible for writing orders and dosing of buprenorphine in the detox program. All policies and policy reviews will be completed by June 1, 2019. The medical director will be responsible for oversight and adherence to this policy. |
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
The facility failed to document a complete client record which included discharge summaries and follow up in 4 of 5 discharged client records.
Five discharge records were reviewed on April 2-4, 2019. Four of the discharged client records reviewed did not include documentation of a discharge summary and/or follow up.
Client #5 was admitted on October 20, 2018 and discharged on November 22, 2018. Client record #5 did not include documentation of follow up.
Client #6 was admitted on February 25, 2019 and discharged on March 17, 2019. Client record #6 did not include documentation of a discharge summary and follow up.
Client #10 was admitted on November 2, 2018 and discharged on November 27, 2018. Client record #10 did not include documentation of follow up.
Client #11 was admitted on November 30, 2018 and discharged on December 28, 2018. Client record #11 did not include documentation of follow up.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counseling staff will attend a training on May 8, 2019 focused on properly completing a discharge summary and follow up contact, and the importance of completing these documents on time. Chart audits will be completed two times monthly by the clinical supervisor with a focus on these specific documents for all counselors, and any missing documentation will be addressed in individual supervision and through PAATC discipline policy. The clinical program director will ensure completion of this training and ongoing compliance. |