INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that counselor assistants documented to the facility director, upon the completion of each calendar year, that they are continuing to work towards counselor status in one of one applicable personnel records reviewed.Employee # 5 has been in the position of counselor assistant since December 6, 2023. There was no documentation to the facility director that they were working toward counselor status by the end of the 2024 calendar year as of the date of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each Counselor Assistant is required to submit in writing to the Project Director that they are working towards Counselor status by December 31st. Effective June 1, 2025, it will be the responsibility of the Project Director to meet with each Counselor Assistant by November 15th to review progress, clarify goals and to discuss any obstacles and/or barriers. This meeting will also serve as formal notification of the December 31st deadline to receive the letter that they are working towards counselor status. This meeting will be documented and signed by the Counselor Assistant. It will be the responsibility of the Facility Director to ensure that the progress letter is placed in the employee's personnel file. If the Counselor Assistant has not submitted the letter that they are working towards Counselor status by December 15th the Facility Director will issue a letter to Counselor Assistant as a reminder of the December 31st deadline. It will be the responsibility of the Facility Director to place the letter from the Counselor Assistant indicating that they were working toward counselor status in the employee's personnel file. Effective July 1, 2025, the facility will be in full compliance.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one applicable employee received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.Employee # 5 has been in the position of counselor assistant since December 6, 2023 and was due to have the communicable disease trainings no later than December 6, 2024. However, the communicable disease trainings were not completed as of the date of the inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon hire, the Project Director will inform the Counselor Assistant of the training requirements during the New Hire Orientation. Effective June 1, 2025, The Project Director will assign the required 6-hour and 4-hour communicable disease training to the Counselor Assistant as part of the new employee onboarding to be completed within the first 3 months of employment. A training log for the counselor assistant will be maintained and monitored by the Project Director. The training log will be reviewed at the 3-month and 6-month mark. A reminder will be issued in writing by the Project Director if the trainings have not been completed at those scheduled reviews. Once the trainings are completed the certificate will be given to the Project Director to be marked complete on the training log. A copy of the certificate will be placed in employees personnel file by the Project Director. The Program Assurance Liaison will conduct a quarterly review of the training log to ensure all counselor assistants trainings are in compliance. Non-compliance will be flagged and reported to the Facility Director within 48 hours. The Facility Director will meet with the Counselor Assistant within 3 business days with a scheduled date and time to complete the training. The Counselor Assistant will complete 6 hours HIV/AIDS and 4 hours of TB/STD and submit completion certificate on 6/30/25. Effective July 1, 2025, the facility will be in full compliance. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and First Aid training certificates provided by the facility, the facility failed to ensure that at least one person trained in First Aid was onsite during the project's hours of operations. From 07:00 a.m. - 10:00 a.m. on Saturdays and Sundays, the facility did not have staff trained in First Aid. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 1, 2025, The Samara House of CYWA has included a mandated CPR/First Aide Training thru the National CPR Foundation to be completed as a part of the onboarding process. The newly hired employee, to include the positions of Counselor, Counselor Assistant and Residential Technician, will be required to complete the CPR/First Aide training within the 1st 7 days of accepting the position. Proof of Certification must be submitted to the Project Director before being placed on the schedule. The Project Director will add the certification to the training log and place a copy in the employee's personnel file. It will be the responsibility of the Facility Director
to review the CPR Log monthly to ensure all CPR certifications are up to date. Effective 5/16/25, the Counselor Assistant will complete the CPR/First Aid training on 5/16/25 and submit certification to the Facility Director. Effective June 01, 2025, the facility will be in full compliance.
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 40 clock hours of training required for counselor assistants during the first year in one of one applicable personnel records reviewed. Employee # 5 has been in the position of counselor assistant since December 6, 2023. The employee was required to complete 40 hours of training between December 6, 2023 and December 5, 2024. The personnel file documented 20.5 hours of training during the period reviewed.These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Effective June 1, 2025, upon hire for the position of counselor assistant, the Project Director will meet with the counselor assistant to provide an overview of the 40-hour annual training requirement as a part of the onboarding process. The Project Director will meet with the counselor assistant within 30 days of hire to develop an individual training plan which will be placed on the training log that will be maintained and monitored by the Project Director. The Facility Director will forward training opportunities bi-monthly. The Program Assurance Liaison will send quarterly reminders showing completed and remaining training hours. All counselor assistants must submit final training certificates by December 15th. The Program Assurance Liaison will confirm each staff members training compliance by December 31st. Effective July 1, 2025, the facility will be in full compliance. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection on April 10, 2025, the facility failed to maintain protective caps over each electrical outlet as one outlet in Bedroom 9 did not have a protective cap. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 1, 2025, it will be the responsibility of the dayshift Residential Technician to complete a walk thru of the floor each day and inspect the areas of the floor according to the check list developed in accordance with DDAP regulations which includes inspecting all electrical outlets. The completed checklist will be placed in the Samara House Plant Inspection Log. If there are any areas that require repairs, it will be the responsibility of the Residential Technician to complete a work order and give to Facility Director. It will be the responsibility of the Facility Director to review the work order with the maintenance engineer and arrange the repair. It will be the responsibility of the Project Director to review all work orders submitted each month and ensure that they have all been completed. When the Project Director has confirmed that the repair has been done the work order will be marked complete and filed in a tracking log managed by the Project Director. On 4/11/25 the Maintenance Engineer secured the outlet with a cover. Effective June 1, 2025, the facility will be in full compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.Client # 4 was admitted on August 8, 2024 and discharged Against Medical Advise (AMA) on October 8, 2024. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Effective June 1, 2025, the facility has created a procedure to be carried out by the Facility Director, Counselor and/or Case Manager within 12 hours after a client has left the facility AMA. It will be the responsibility of the Counselor, Case Manager or Residential Technician on duty to immediately notify the Facility Director when a client leaves the facility AMA. It will be the responsibilty of the Counselor, Case Manager and/or Facility Director to notify the clients emergency contact within 12 hours after the client has left the facility AMA. The communication to the emergency contact will be documented on the Samara House Follow-Up Form that will be placed in the After-Care Log. Effective June 1, 2025, the facility will be in full compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every thirty days in three of six applicable records reviewed.Client # 1 was admitted on May 28, 2024 and was discharged on August 21, 2024. A treatment plan update was completed on June 20, 2024, and the next treatment plan update was due no later than July 20, 2024; however, the treatment plan update was not completed until July 29, 2024. Client # 4 was admitted on August 8, 2024 and was discharged on October 8, 2024. The individual treatment and rehabilitation plan was completed on August 9, 2024, and the treatment plan update was due no later than September 8, 2024; however, the treatment plan update was not completed until September 12, 2024. Client # 5 was admitted on June 21, 2024 and was discharged on January 21, 2025. A treatment plan update was completed on September 17, 2024, and the next treatment plan update was due no later than October 17, 2024; however, the treatment plan update was not completed until October 22, 2024. The next treatment plan update was due to be completed by November 21, 2024; however, it was not completed until November 25, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 1, 2025, It will be the responsibility of the Counselor with support of the Facility Director to ensure that all clients have an individualized up-to-date treatment plan created within 24 hours of admission and updated as needed in addition to creating a Treatment Plan Update every 30 days according to Samara House Policy and Procedures and DDAP regulations and standards. It will be the responsibility of the Facility Director to ensure that the Counselor meets with the client within the 1st 24 hours of the client's admission. All Initial Treatment Plans need to be reviewed and signed by the client and Facility Director by the end of the business day of the client's 1st 24-hour day of admission. It will be the responsibility of the Counselor to develop a 30-Day Treatment Plan Update to be reviewed and signed by the Facility Director by the end of the business day on the 30th day. It will be the responsibility of the Residential Tech/Night Auditor to perform weekly chart audits in conjunction with the Project Director. Non-compliances will be reported to the Project Director within 1 business day. It will be the responsibility of the Project Director to notify the Counselor and Facility Director with a written correspondence of the non-compliance with an expected completion date in accordance with the Samara House Timeline. The document will be submitted to the Project Director and will be reviewed with the Counselor and Facility Director for accuracy and completeness then placed in the to be filed folder by the Counselor. Effective June 1, 2025, the facility will be in full compliance. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in two of five applicable records reviewed. Client # 2 was admitted on July 29, 2024 and was discharged on October 4, 2024. The record did not contain documentation of follow-up information.Client # 4 was admitted on August 8, 2024 and was discharged on October 8, 2024. The record did not contain documentation of follow-up information.This is a repeat citation from the April 4, 2024 and April 14, 2023 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 1, 2025, it will be the responsibility of the Case Manager and Counselor Assistants to ensure ongoing support and continuity of care for clients discharged from treatment services. To meet regulatory requirements for post-discharge, follow-ups will be conducted within 24 hours for clients who AMA and 7-day, 3 month and 6 months for all other discharges. Attempts for contacting discharged clients will be via phone, email, text or letter. Each attempt will be documented on the Samara House follow-up form. It will be the responsibility of the Night Auditor to review the After-Care Log bi-weekly, document any missing contact attempts and provide a copy to the Facility Director for follow-up with the client directly or Case Manager. Effective June 1, 2025, the facility will be in full compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for completing follow-up information was submitted and approved by the Department for the April 14, 2023 and April 4, 2024 annual licensing inspections. Failing to complete follow-up information was again found to be a deficiency in the April 10, 2025 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 1, 2025, It will be the responsibility of the newly hired Project Director to review the weekly chart audit to ensure that client records are managed, monitored and maintained and that all required services are being delivered according to policy and procedure and are in accordance with DDAP Regulations. The Lead Residential Technician will conduct weekly chart audits in conjunction with the Project Director. The results of the audit will be reported to the Facility Director by the Project Director within 3 business days. The Facility Director will notify the Counselor by way of written correspondence of the non-compliances and a date for completion of documents will be given as to adhere to program timelines. The Counselor will work along with Facility Director to review documents for clinical accuracy. The Projector Director in conjunction with the Facility Director will work together and perform a quarterly audit of all Plan of Corrections to ensure that the program remains compliance. |