INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 07, 2010 and April 08, 2010 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 and a plan of correction is due on April 30, 2010.
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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
Based on a review of six personnel records on April 7, 2010 and an interview with the facility director the facility failed to ensure that each counselor met the qualifications for the position in one of two as required.
Findings:
Based of the reveiw of personnel records, employee # 4, did not meet the qualifications for the position of counselor. The facility failed to ensure that employee # 4 had the 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency that is required according to the staffing guidelines.
The facility director was interviewed on April 7, 2010 and was informed that employee # 4 did not meet the qualifications for counselor. The facility director understood that this staff member would need to be designated a counselor assistant.
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Plan of Correction
As of 4/8/10, employee #4, who does not meet Counselor qualifications has been changed to Counselor Assistant. Personnel file reflects the same. Six (6) month Training Plan has been developed. The Director and Senior Counselor will share in supervision of this Counselor Assistant along with documentation and sign-off on progress notes, treatment plans, case consults and treatment plan updates. To continue for a period of 6 months and then, if satisfactory, will follow State Regulations to promote to Counselor.
Persons responsible: Director and Senior Counselor.
Begin date: 04/08/10
Evaluate at 6 months for promotion, if performance is satisfactory. |
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 record (#1) and an interview conducted on April 8, 2010, it was determined that the facility failed to ensure that the Project Director had the required training hours.
The findings were:
A review of personnel record #1 was conducted April 7, 2010. A review of training documentation in the record indicated that employee #1 failed to obtain the required 12 clock hours of annual training. Employee #1 did not have any training hours documented for the training year of July 1, 2008 through June 30, 2009. This was confirmed on April 8, 2010 by the facility staff.
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Plan of Correction
Annual training questionnaire to be reviewed on 4/18/10 with Executive Director and then training of 12 hours to be completed by July 1, 2010.
Person responsible: Executive Director |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of current client census information, clinical staff hours and an interview with the facility director, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every eight clients, as required by regulation.
The findings include:
The current client census information and clinical staff hours were reviewed on April 7, 2010. Per regulation, inpatient non hospital treatment and rehabilitation projects serving adult clients shall have one FTE counselor for every eight clients. The facility employed two counselors; however, the one counselor (employee # 4) did not meet the requirements to be a counselor and could not be included in the equation to determine the client counselor ratio. Based on this information, the staff client ratio was 13:1; which exceeded the required 8:1 ratio.
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Plan of Correction
During primary care hours, the Director will supervise the Counselor's Assistant's caseload of 6 clients so as to keep proper ratio.
Person responsible: Director
This process will continue for 6 months, then staff will be evaluated for possible promotion following State Regulations.
Begin date: 04/08/2010 |
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
Based on a physical plant tour, the facility failed to ventilate toilet and wash rooms by exhaust fan or window.
The findings include:
A physical plant tour was conducted on April 7, 2010 from 2:00 P.M. to 3:00 P.M.. All bathrooms were required to have ventilation by exhaust fan or a window. The facility failed to provide a source of ventilation in the male bathroom located in the basement of the facility.
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Plan of Correction
An exhaust fan will be installed in the basement male bathroom in the ceiling and then run a 4" line out to the side of the building.
Person responsible: Director of Maintenance & Housing
To be completed by: June 15, 2010 |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant and a staff interview, the facility failed to provide documentation of hot food temperature logs.
The findings include:
The physical plant was toured on April 7, 2010 from 2:00 P.M.. to 3:00 PM. The facility failed to provide a hot food temperature log. The facility failed to document hot food temperatures ensuring hot food is served at or above 140 degrees. A staff interview confirmed that a hot food temperature log had not been maintained.
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Plan of Correction
A Hot Food Log will be developed on 4/23/10 by Director following State Regulations. Staff training will be on 4/23/10 and Hot Food Logs will be done daily by the Counselors' Aides. Senior Counselor and CQI/Nurse will ensure accuracy of compliance.
Person responsible: Director, Senior Counselor, CQI/Nurse
Begin date: 4/26/10 |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant tour the facility failed to maintain each interior stairway exceeding two steps with a well-secured handrail.
The findings include:
Based on the physical plant tour on April 7, 2010 between 2:00 P.M. and 3:00 P.M. it was observed that the facility failed to have a handrail in place leading to the emergency exit from the basement. This exit had seven steps and therefore needed to have a well-secured railing.
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Plan of Correction
Handrails will be installed leading to the emergency exit from the basement.
Person responsible: Director of Housing & Maintenance
To be completed by: June 15, 2010 |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment.
The findings include:
Based on a review of five client records on April 8, 2010, one record was required to have a notification of involuntary termination. The notification of termination was missing in client record #3.
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Plan of Correction
Although 72 hour notice was given to client #3, it could not be produced at time of visit.
Training on how to complete Notice of Discharge form and Grievance Policy will be given to Counselors on 4/28/10 at scheduled staff meeting. As of that date, the Director and Senior Counselor will check all client files for proper notification and documentation.
All discharges/terminations must be approved by the Director.
Person responsible: Director and Senior Counselor
Begin date: 4/28/10 |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision terminating treatment.
The findings include:
Five client records were reviewed on April 8, 2010. The project was required to give the client an opportunity to request reconsideration of a decision terminating treatment in one client record. The project did not document that the client was given an opportunity to request reconsideration in client record # 3.
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Plan of Correction
Discharge form and Grievance Policy will be given to Counselors on 4/28/10 at scheduled staff meeting. As of that date, the Director and Senior Counselor will check all client files for proper notification and documentation.
All discharges/terminations must be approved by the Director.
Person responsible: Director and Senior Counselor
Begin date: 4/28/10 |