INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 7 through April 8, 2010 licensure renewal inspection. The follow-up inspection was conducted on November 22, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 December 23, 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 personnel records.
Findings:
Based of the review of personnel records on November 22, 2010, the employee # 4 did not meet the qualifications for the position of counselor. The facility failed to ensure that employee # 4 had 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 November 22, 2010 and was informed that employee # 4 still did not meet the qualifications for counselor. The facility director understood that this staff member would need to remain a counselor assistant until they obtained one year experience in the drug and alcohol field.
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Plan of Correction
L0037 As of 11/23/10 documentation was placed in employee # 4's personnel file to carry full caseload as a Counselor's Assistant until February 2011. She will continue to be supervised with documentation. Person responsible to ensure this procedure is the Facility Director. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of supervisory documentation and an interview with the clinical supervisor, it was determined that employee # 4 did not have the required six months of documented supervisory sessions.
The findings include:
The documentation of close supervision for the first six months as a counselor assistant for employee # 4 was reviewed on November 22, 2010. The facility failed to provide six months of supervisory documentation as there was no documentation for the month of October 2010. An interview with the Clinical Supervisor confirmed that the documentation for October could not be found.
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Plan of Correction
L0049 The Clinical Supervisor will continue to supervise the Counselor's Assistant until February 2011 with documentation. If this Counselor's Assistant has a satisfactory performance, she then will be promoted to Counselor. Person responsible for this achievement is the Facility Director. |
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 an interview conducted on November 22, 2010, it was determined that the facility failed to ensure that the Project Director had the required training hours.
The findings were:
An interview with the facility director took place on November 22, 2010 at approximately 10:00 a.m. It was confirmed that the Project Director, employee # 1, did not receive the required training hours for the July 1, 2009- June 30, 2010 training year.
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Plan of Correction
L0075 The Project Director has completed 3 hours of training as of November 30, 2010 - our 2010-2011 training year. A training plan has been created for the remaining 9 hours. Person responsible to ensure completion is the Facility Director. Training will be completed by June 30, 2011. |
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 a staff interview, the facility failed to provide documentation of hot food temperatures.
The findings include:
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 on November 22, 2010 confirmed that facility staff are unaware of hot food temperatures.
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Plan of Correction
P079 As of November 23, 2010, a log was created to check hot food temperatures ensuring hot food is served at or above 140 degrees. Staff on duty will complete each login at the time of the meals. Person responsible to supervise will be the Senior Counselor with Facility Director overseeing. |
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 November 22, 2010 at 10:10 a.m. until 10:30 a.m. it was observed that the facility failed to have handrails in place leading to the emergency exit from the basement. This exit two has two sets of steps leading to the exit. The first set had seven steps and therefore needed to have a well-secured hand rail. Additionally, there was a second set of four steps leading to an external exit that also required a well-secured handrail but one was not in place.
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Plan of Correction
P109 On November 29, 2010, handrails were installed in the emergency exit from the basement - properly secured. Handrail was secured as well on November 29, 2010 at the second set of four steps leading to an external exit. Person responsible for compliance was Maintenance Director who will continue to check monthly to make sure all handrails are still secure. |
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 and the facility policy and procedure manual, 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 six client records on November 22, 2010, six records were required to document notification of an involuntary termination. According to the facility policy and procedure manual, "clients will receive written notice of termination. This notification will include termination date, reason for termination and will advise the client of her right to appeal as outlined in the resident handbook. Client's will receive this notice prior to leaving if this is not possible it will be mailed to them. The notification of termination was missing in client records # 1, 2, 3, 4, 5, and 6.
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Plan of Correction
L0333 At the time of the licensing visit, the termination letters were placed in our Follow-Up Log which we didn't produce at the time of licensing. All of these notices were given. The Facility Director will continue to supervise each discharged client to make sure they are given notice. A copy of the 72-hour termination letter will go in the Follow-Up Log and Client File. This procedure is immediate to ensure termination date, reason and right to appeal. If client is not here, the notice will be mailed. |
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 a review of client records and the facility policy and procedure manual, the facility failed to provide the client the opportunity to request reconsideration of the decision of terminating treatment.
The findings include:
Based on a review of six client records on November 22, 2010, the project was required to give the client an opportunity to request reconsideration of a decision to terminate treatment in six client records. According to the facility policy and procedure manual, "clients will receive written notice of termination. This notification will include termination date, reason for termination and will advise the client of her right to appeal as outlined in the resident handbook. Client's will receive this notice prior to leaving if this is not possible it will be mailed to them. The project did not document that the client was given an opportunity to request reconsideration in client records # 1, 2, 3, 4, 5, and 6.
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Plan of Correction
L0335 The Facility Director will continue to supervise each discharged client to make sure they are given notice. A copy of the 72-hour termination letter will go in the Follow-Up Log and Client File. This procedure is immediate to ensure termination date, reason and right to appeal. If client is not here, the notice will be mailed. Person responsible to ensure compliance is Facility Director. |