INITIAL COMMENTS
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This report is a result of compliant investigation conducted on June 6, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Samara House of CYWA were substantiated. Samara House 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:
The following deficiencies were identified during this inspection:
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Plan of Correction
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705.8 (1) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
Based on an interview with clients and staff, the facility failed to provide a cooling ventilation system such as fans or air conditioning that is adequate to maintain an indoor temperature s exceed 90 F.
The findings include:
The temperatures during the last two days of of June 2012 and first week of July 2012 exceeded 90 Farenheit and heat indexes were over 102 degrees. On July 9, 2012, the Licensing Specialist interviewed several clients and staff at the facility. Some of the clients stated that the facility's air-conditioner was not working for several days during the last week of June 2012 and the first week of July 2012. Staff also stated that the air conditioner had not been working and that a work order to get it repaired was submitted.
The findings were confirmed during interviews with clients and staff on July 9, 2012.
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Plan of Correction
The facility's air conditioner has been repaired and is working properly.
To ensure this continues, the Samara House staff on duty on the floor will check daily and log to be kept to insure indoor temp. to be at least 65 degrees Farenheit in the winter and indoor temps in warm weather not to exceed 90 degrees Farenheit. If heat or ac units are not properly working, a repairman will be contacted. In warm temp, if the air central unit is not working fans and/or window ac units will be purchased or rented immediately by the CYWA maintenance staff until problem has been remedied by professional repair.
Persons responsible to ensure compliance - Facility Director and Project Director.
This procedure was explained to maintenance and Samara House staff on 7/25/12, to begin immediately. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on observation and interviews with clients and staff, the facility failed to limit smoking to designated smoking areas.
The findings include:
The facility was required to limit smoking to designated smoking areas outside the facility. On July 9, 2012, the Licensing Specialist interviewed several clients and staff at the facility. Some of the clients and staff acknowledged that the facility director and project director have smoked in the project director's office. During the physical plant inspection, the Licensing Specialist noted the odor of cigarette smoke in the director's office.
The findings were confirmed during interviews with clients and staff on July 9, 2012.
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Plan of Correction
As of 7/11/12, Project Director and Facility Director were given written warning as to smoking in Project Director's office. This was documented in each personnel file.
An outside table with umbrella was placed in posted smoking area on the patio outside of the building.
Both Facility Director and Project Director have agreed to follow direction and procedure.
Attorney/Director will walk through the building 3X's daily to ensure "no smoking", except in designated areas. Anyone breaking policy will be referred to Executive Director or if in violation, incident will be referred to the President of the Board for further action.
Any further incidents will result in written warning and procedures outlined per the CYWA Staff Handbook which also includes EAP.
Effective immediately - to be enforced by the CYWA Board of Directors.
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709.26(a)(7) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(7) Rules of conduct.
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Observations
Based on interviews with clients and staff, the governing body failed to adopt and implement written project personnel policies and procedures for rules of conduct.
The findings include:
On July 9, 2012, the Licensing Specialist interviewed several clients and staff at the facility regarding the allegations that the maintenance man had walked into the bedrooms of clients while they were undressed. or in various stages of dress. Clients and staff confirmed that there had been occasions when the maintenance man walked into the bedrooms of clients while they were undressed or in various stages of dress. The facility indicated that they recently implemented a protocol to address the conduct with the maintenance man; however, on July 9, 2012, when the Licensing Specialist asked to see the facility's project written policies and procedure to address the conduct with the maintenance man, they were unable to produce one.
The findings were confirmed during an interview with the facility director on July 9, 2012 at approximately 1:00 P.M.
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Plan of Correction
The CYWA Personnel Policy Procedures for - "Rules of Conduct for Maintenance Staff and Outside Service Repair Persons" was written on 7/25/12.
The Board of Directors, responsible to adopt and implement policy, will meet on 7/30/12 to adopt said policies and procedures. Facility Director, Clinical Supervisor, CQI/LPN staff are responsible for implementation in the facility. Policy to be effective 7/30/12.
Repairmen and maintenance to be accompanied by on duty staff on Samara House floor at all times.
Clinical Supervisor and CQI will make sure policy is in place.
All work orders are filled out and given to the Facility Director who will set up times for maintenance to do work on the floor and report to the Clinical Supervisor and CQI to monitor.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on observations on July 9, 2012, the facility failed to maintain the confidentiality of client identity. in drug and alcohol treatment as they
The findings include:
A physical plant inspection was conducted on July 9, 2012. It was observed during the inspection at approximately 12:00 P.M., that the facility was holding life skills sessions outside on the facility's patio, where clients can easily be observed and identified.
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Plan of Correction
As of 7/25/12, the Facility Director met with all clinical and prevention staff to review the Confidentiality regulation regarding client identity in drug and alcohol treatment. All staff was advised they could not hold any group or life skills on the patio of the CYWA/Samara House.
Persons responsible to oversee that this does not occur are the Clinical Staff, Prevention Specialist and Facility Director.
Effective 7/25/12.
Policy was explained to all staff. Clinical Supervisor will be responsible for overseeing and making sure the confidentiality is upheld. |