INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Samara House of CYWA 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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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on interviews with clients, the facility failed to ensure support services were being provided in accordance with the individual treatment and rehabilitation plan.
The findings include:
Five clients were interviewed during the licensing inspection that was conducted at the facility on November 19, 2014. Two clients reported that there have been missed medical appointments due to the van driver not arriving for his scheduled shift on time or at all.
The Project Director confirmed there had been one occasions where a client was unable to make it to a scheduled appointment at the Narcotic Treatment Program due to the driver not showing up. The appointment was one of a series of five that are required for the client to participate at the treatment program.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the April 23, 2014 complaint investigation.
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Plan of Correction
As of 11/24/14, the Facility Director met with full-time Driver to discuss missed appointments. A verbal warning has already been issued. There will be a written warning following the CYWA Personnel Policy as of this date.
Back-up drivers (3 staff) and Facility Director will drive when full-time Driver cannot make it due to any emergency as of 11/28/14.
CQI and Facility Director will monitor and will be given schedules weekly. |
704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
Based on interviews with clients, it was determined that the facility failed to demonstrate awake staff coverage 24 hours a day.
The findings include:
Five clients were interviewed during the licensing inspection that was conducted at the facility on November 19, 2014. Two clients reported that the second shift staff person and the overnight staff person on duty have been observed sleeping on numerous occasions.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the April 23, 2014 complaint investigation.
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Plan of Correction
As of 12/8/14, the 2nd and 3rd shift employees were given a written warning by Facility Director regarding sleeping on their respective shifts. Previous verbal warnings were given. The Facility Director will follow Personnel Policy if there are any reported incidents of sleepig that occur. This could include referral for Employee Assistance Program (EAP) or dismissal.
Both staff will be placed on 90-day probationary period and will include random checks and conversations with clients by Facility Director and CQI.
Persons responsible: Facility Director and CQI |