INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 22, 2015 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:
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two counselor records reviewed.
The findings include:
Two personnel records of counselors requiring the documentation of the completion of 25 clock hours of annual training were reviewed on December 22, 2015. The facility failed to document the completion of 25 clock hours of annual training for employee #4.
Employee # 4 was hired on October 3, 2011 as a counselor. The facility training year is from July through June. The training year for July 2014 to June 2015 was reviewed. Employee # 4 only completed 19 clock hours of annual training for the July 2014 to June 2015 training year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 12/27 training will be assigned as requested in Training questionnaire by CQI, LPN. Trainings will be scheduled through DDAP, notice of confirmed training will be given to staff for attendance. Required training hours to be completed by fiscal year. CQI, LPN will check available training monthly through DDAP system. CQI, LPN will assure training scheduled quarterly. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
Based on observation during the physical plant inspection, the facility failed to ensure that all trash, garbage and rubbish was stored in noncombustible, covered containers that prevents the penetration of insects and rodents.
The findings include:
The physical plant inspection was conducted on December 22, 2015 at approximately 11:00 am. Trash/garbage containers were observed behind the facility, in a row along the alleyway. Four of these containers had broken or no covers to prevent the penetration of insects and rodents.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Waste Management Services was contacted on 1/6/2016 and will deliver new trash/garbage containers on or before 1/15/2016. Maintenance will continue to inspect containers daily to insure lids are operable and closed.
Person responsible: Maintenance
Process to begin on 1/15/2016 |
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.
|
Observations
Based on observation during the physical plant inspection, the facility failed to ensure that food was being keep cold at or blow 40 degrees fahrenheit in one of two refrigerators in the kitchen area.
The findings include:
A physical plant inspection was conducted on December 22, 2015 at approximately 11:00 am. The facility utilizes a thermometer in both the refrigerator and freezer portions of their appliances. During the inspection, one of the refrigerators had a thermometer displaying 46 degrees fahrenheit. A check on this same thermometer was made approximately two hours later and it was observed at 44 degrees fahrenheit.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Zachary Appliances was called to service refrigerator in Samara House on 1/5/2016. Temperature will be checked and logged three times daily. If any abnormal temperatures occur, refrigerator will then be replaced immediately.
Person responsible: CQI and Lead Counselors Aide
Beginning 1/5/2016 |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
|
Observations
Based on a review of personnel records, the facility failed to document an annual performance evaluation in one of four applicable personnel records.
The findings include:
Four personnel records requiring documentation of an annual performance evaluation were reviewed on December 22, 2015. The facility failed to document an annual performance evaluation in personnel record # 1.
Employee # 1 was hired as the Executive Director on July 1, 1991. There was no documentation of the completion of a performance evaluation in this employee's record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Due to changing of Board Members, Executive Directors performance evaluation for 2014 was not retained. The performance evaluation for 2015 for Executive Director has been completed and returned on 1/6/2016. Executive Director will insure the performance evaluation be completed by January 1 every year and signed by the Board effective January 1, 2016. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client records, the facility failed to document that a physical examination was performed in two of six client records reviewed.
The findings include:
Six client records requiring documentation of a physical examination were reviewed on December 22, 2015. The facility failed to complete physical examinations as part of the intake process in client records, #3 and 4.
Client #3 was admitted on April 7, 2015 and was discharged on September 28, 2015. The intake process was completed on April 9, 2015, but there was no physical examination documented in the client record as of the date of this inspection.
Client # 4 was admitted on April 20, 2015 and was discharged on November 24, 2015. The intake process was completed on April 24, 2015, but there was no physical examination documented in the client record as of the date of this inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 12/27/2015 all clients being admitted to Samara House will be required to present a current physical at time of admission (physicals must be within one year).
Person responsible for implementation: CQI/LPN and Clinical Supervisor |