INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10 and 11, 2011 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 May 14, 2011.
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on the review of policy and procedure manual and an interview with the facility director, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
The policy and procedure manual was reviewed on March 10, 2011. According to the staffing requirements facility summary report completed by facility staff, the facility's training year runs according to the fiscal year, July 1, 2010 - June 30, 2011. The policy and procedure manual stated that, "at least annually the facility training program will be evaluated by the Executive Director". The facility director was requested to provide the licensing specialist with the annual evaluation of the training plan. For the purpose of this review, the annual evaluation of the training plan was requested for the July 1, 2009 through June 30, 2010 training year. The annual evaluation for the July 1, 2009 through June 30, 2010 training year was not provided during the licensing inspection. The facility director confirmed this finding at 10:50 a.m. on March 11, 2011.
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Plan of Correction
Overall Training Evaluation Summary completed at time of inspection but was not located at time of inspection, was located in Policy & Procedure Manual. Summary to be completed by July 1, annually by CQI personnel. Staff will be assigned trainings quarterly by CQI and approved by Director, based on availability of trainings through BDAP. Annual questionnaires to be collected and placed at the front of the Operations Manual, along with training certificates and training forms, as training is completed. Bi-annual checks will be made to ensure trainings are being completed by staff (Nov.).
Training evaluation summary will be located in Section 704, Staff Requirements of the policy and Procedure Manual. Yearly process of completing summary to begin May 1 with review of questionnaire finalized by June 30 of overall trainings.
Person responsible - CQI
Facility Director to ensure trainings are scheduled and attended and yearly training evaluation summary is completed and placed in Policy and Procedure Manual and easily visible for review during monitoring to ensure ongoing compliance. |
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 the project director's personnel record (#1) and an interview, it was determined that the facility failed to have the project director complete at least 12 clock hours of training, as required.
The findings include:
A review of personnel record #1 was conducted March 10, 2011. Training documentation in record #1 indicated only 3 clock hours of the required 12 clock hours were completed in the July 1, 2009 to June 30, 2010 training year. During an initial interview with the project director on March 10, 2011 at 10: 50 A.M., it was confirmed that personnel #1 failed to complete the required 12 clock hours of annual training.
This is a repeat citation from the April 7 - 8, 2010 licensing visit. The plan of correction for the citation stated:
"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 "
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Plan of Correction
The Project Director was informed of this non-compliance due to not completing 12 clock hours of training for July 1, 2009 to June 30, 2010 which is a repeat finding from April 7-8,2010 on 4/25/11.
The Project Director has registered for the following audio trainings as of 4/28/11 from J&K Seminars, Lancaster, PA:
- Treating Angry & Aggressive Children, Adolescents & Adults
- Healing from Loss & Abandonment
- Treating PTSD
Understanding Psychopaths
All trainings are 12 hours each, online, approved CE's and will complete trainings required per annual training questionnaire and this regulation by the end of training year 2010-2011.
Person responsible - Executive Director
Online video trainings will be scheduled for staff viewing quarterly to ensure compliance. Videos equal 12 credits; 6 videos have been ordered. Certificates of completion to be printed upon viewing.
Training on site and off site to be scheduled by CQI quarterly or as available by BDAP. Training evaluations to be completed upon completion of training.
Review of training-to-date to be completed semi-annually for assurance.
Person responsible for compliance - CQI |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation during the physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.
The findings include:
A physical plant inspection took place on March 11, 2011 between the hours of 8:45 a.m. and 10:00 a.m. It was observed during the physical plant inspection that the heating system closet on the third floor was used for storage, in addition to housing the facility's furnace. The inspection revealed that a roll of carpet was leaning against the furnace. There were also window screens, a bucket of paint, a ladder/stepstool, extension cord, and other random items stored in the heating system closet. The storage of these items in the heating system closet reduced the ventilation for the heating system and created a potential fire hazard.
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Plan of Correction
As of March 3, 2011, the heating system closet was cleaned out by maintenance and the staff was given a directive to store no items in this closet due to hazards and poor ventilation.
Persons responsible for weekly check to ensure compliance is staff on duty -Clinician and Lead Counselor's Aide. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on the physical plant inspection, the facility failed to provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
During the physical plant inspection on March 11, 2011, between 8:45 AM and 10:00 AM, the visitor's bathroom was inspected in the basement of the facility. The sink in the female bathroom was observed not to drain properly; there was standing water in the sink following the licensing specialist's test to determine water temperature.
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Plan of Correction
Maintenance staff was informed of this non-compliance as of 4/25/11. The drainage in the female bathroom was repaired and drainage was working properly. This will be checked daily by the maintenance staff and repaired immediately if not working properly.
Person responsible - Director of Maintenance |
705.24 (6) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant tour it was observed that the facility failed to provide toilet paper in the woman's restroom.
The findings include:
A physical plant inspection took place on March 11, 2011, between 8:45 AM. and 10:00 AM. The woman's visitor restroom in the basement did not have toilet paper in either of the two stalls. The clinical supervisor confirmed that there was no toilet paper in either stall during the physical plant inspection.
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Plan of Correction
Maintenance staff was informed of this non-compliance as of 3/11/11. Staff will check all bathrooms 2 X's daily (am & pm) to ensure the bathroom has toilet paper in both stalls in the basement, as well as other bathrooms in the building.
Person responsible - Director of Maintenance |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant tour, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
A physical plant tour took place on March 11, 2011 between the hours of 8:45 a.m. and 10:00 a.m. There was a bathroom at the end of the hall on the third floor that was not clean and sanitary. This bathroom was observed to be dirty and not maintained as evidenced by dirt found in the sink and a dried up sponge and other debris on the bathroom floor. Additionally, there was no shower curtain in place in the shower stall.
An interview with the clinical supervisor confirmed that this bathroom does not get used due to the hot water taking a long time to reach the shower. It was confirmed that they can use the toilet and sink in this bathroom.
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Plan of Correction
Samara House staff was informed of this non-compliance and regulation as of 4/25/11. This bathroom has been put on routine chores and will be maintained as a working bathroom as of 6/15/11. A shower curtain will be installed as of May 15, 2011. A hot water unit will be installed as of June 15, 2011.
Person responsible for maintaining cleanliness is on duty staff and Lead Counselor's Aide.
Person responsible for installation of the hot water unit is the Director of Maintenance. |
705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which 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 follow their policy and procedure and failed to follow their plan of correction from the November 23, 2010 unannounced follow-up inspection. The facility failed to maintain a hot food temperature log. A staff interview on March 11, 2011 confirmed that documentation was not available indicating what the hot food temperatures were. The staff produced a blank temperature food log that had not been used. Additionally, the licensing inspectors looked in the kitchen drawers and cupboards and were unable to locate a mechanism for taking hot food temperatures.
This is a repeat citation from the April 8, 2010 licensing inspection and the November 23, 2010 unannounced follow-up inspection. Interviews conducted during these prior inspections revealed that staff were unaware of temperatures for the hot food being served to the clients. In an effort to address this concern, the facility determined that they would maintain a hot food temperature log.
The plan of correction for the November 23, 2010 unannounced follow-up inspection stated, "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."
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Plan of Correction
Temps for refrigerator and freezer to be taken daily by Aides. Temps to remain: refrigerator - between 40 degrees F or under, freezer 0 degrees or under. Cold and hot food temps to be taken as prepared on daily menu. Hot food temp to be maintained at 140 degrees F. All temps to be recorded and kept in a log book. Cold/hot food thermometers to be stored and kept above the sink on shelf. Aide Supervisor will review temp log book monthly.
Person responsible - Nurse to oversee compliance |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on review of the policy and procedure manual, a review of the fire drill log and an interview with the facility director, the facility failed to prepare and utilize alternate exit routes during fire drills.
The findings include:
The policy and procedure manual and the fire drill log was reviewed on March 10, 2011. According to the facility policy and procedure manual, the facility will "Inform monitors on each level of the time of each drill and designate use of primary or alternate exit routes to be used. Route shall be alternated each month." The facility failed to follow their policy. According to the review of the fire drill log the facility only documented an alternate exit two times in the past twelve months. The facility director confirmed that the alternate exits were not being alternated each month per the facility policy and procedure.
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Plan of Correction
The staff reviewed this regulation and non-compliance areas on 4/27/11. Maintenance staff and Samara House staff were informed of the facility policy and procedure. All agree to use alternate routes for exit during fire drills, every other month.
Person responsible to ensure compliance and log completion is the Director of Housing and Maintenance. He will review monthly. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of administrative documentation and an interview with the project director, the facility failed to present the 2010-2011 project goals and objectives which included time frames and available resources to the governing body.
The findings include:
The facility's 2010-2011 goals and objectives and the board meeting minutes of the governing body were requested for the purpose of review on March 10, 2011. The 2010-2011 goals and objectives were provided, however, no documentation was available to confirm that the governing body approved the goals and objectives. An interview with the project director was conducted on March 10, 2011 and it was confirmed that the project goals and objectives were not presented to the governing body at least annually.
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Plan of Correction
The Project Director was given a copy of regulation 709.23(b)(1) on 4/25/11. A copy of the project goals and objectives, timeframe and resources will be included in the Annual Report given to the Board of Directors. 2010-2011 Goals and Objectives will be presented and reviewed at the quarterly board meeting for June 6, 2011. Goals and Objectives are reviewed and summarized by Facility Director. Compliance with goals is achieved through monthly monitoring by Facility Director. Annual Goals and Objectives to be presented to Project Director from Facility Director and be given to the President of the Board of Directors who will present them at the Annual quarterly meeting on June 6, 2011. Any necessary changes will be addressed at the meeting and corrections made immediately. Review of compliance with Goals and Objectives to be reviewed by the Board at the mid-year board meeting. Meeting to be documented in Board minutes and to state goals and objectives have been approved by governing Board members.
Person responsible for compliance - Project Director |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on the review of administrative documentation and an interview with the facility director, the facility failed to document a performance report summarizing the progress towards meeting the 2009-2010 goals and objectives.
The findings include:
The facility's administrative documentation was reviewed on March 10, 2011. In interviews with the facility director on March 10 and 11, 2011, it was confirmed that there was no documentation of a performance report summarizing the facility's progress towards meeting the 2009-2010 goals and objectives.
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Plan of Correction
The Project Dirctor reviewed this regulation on 3/14/11 and will submit by June 30, 2011, a performance summary towards meeting goals and objectives for 2010-2011 to the Board of Directors by June 30, 2011. 2009-2010 Performance Summary completed and reviewed by Project Director, as of March 17, 2011. 2009-2010 summary was completed and presented to the President of the Board of Directors on March 21, 2011 and approved.
The Project Director will submit to the Executive Director the Goals and Objectives and Summary for past year and present new Goals and Objectives. The Executive Director will check to ensure compliance by June 1 of each year and approval by Board of Directors. Board meeting minutes will be documented to reflect submission and approval. This process will ensure this regulation is in compliance.
Person responsible for compliance - Project Director and Executive Director |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation during the physical plant tour and an interview with the clinical supervisor, the facility failed to maintain client records in a locked storage container.
The findings include:
The physical plant inspection was conducted on March 11, 2011 between the hours of 8:45 a.m. and 10:00 a.m. During the tour, two client records were observed to be placed on top of a file cabinet. Additionally, the lock on the two drawer file cabinet was observed to not be in working order. The clinical supervisor confirmed that the file cabinet would not lock and that the client records were being stored in a storage container that was not locked.
During the inspection, the facility maintenance staff did install two locks on the file cabinet on March 11, 2011.
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Plan of Correction
The facility installed two locks on the file cabineets on March 11, 2011. Staff will report any broken or lost locks immediately to the Director of Maintenance for repair.
Person responsible for daily security will be Senior Staff on duty daily. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based on an inspection of the drug storage area, the facility failed to keep disinfectants and drugs for external use stored separately from oral and injectable drugs.
The findings include:
According to the facility policy and procedure manual reviewed on March 10, 2011, "drugs will be kept in their original containers within the facility's designated medical office in a lockted cabinet." Based on an inspection of the medication file cabinet on March 11, 2011, the facility failed to store disinfectants and drugs used for external use separately from oral and injectable drugs. The topical medications were observed to be stored in the same ziplock plastic bag as the oral medications. The clinical supervisor was present during the inspection and confirmed that the oral and topical medications were stored together.
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Plan of Correction
Beginning April 14, 2011, medication, upon resident admission, to be stored in med cabinet located in Nurse's office. All meds to be documented in MAR. New scripts and deleted medication also to be documented. Oral medication to be stored in individual containers per client in 1st drawer. Oitments stored in individual resident containers in 2nd drawer. 3rd drawer doubled locked for narcotics. Meds to be given to client or disposed of and documented upon discharge. Monthly storage check to be completed by Nurse and signed by Director quarterly. Policy & Procedure to reflect updates 3/14/11.
Persons repsonsible for compliance - Nurse and Director |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual and an interview with the clinical supervisor and the Facility Director, the facility failed to follow their policy and procedure to document quarterly inspections of the medication storage area.
The findings include:
On March 10, 2011, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, drug storage areas are inspected at least once every three months by the Program Director who will submit the medication area inspection checklist to the Executive Director. During the inspection, documentation of the quarterly inspections of the drug storage area was requested by the licensing specialist. The facility director failed to present this documentation for the inspection.
The facility director confirmed that medication storage area inspection documentation was not able to be located. The director stated that the staff member who is responsible for the inspections was not available and they were unable to locate the inspection documentation.
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Plan of Correction
Beginning March 14, 2011, medication will be stored in the Nursing Office:
-Oral medication to be stored in 1st drawer.
-Ointments to be stored in 2nd drawer.
-Narcotics to be double locked in 3rd drawer.
-Refrigerated medications to be stored in designated refrigerator.
-All meds to be labeled and stored separately in original containers per client.
Monthly inspection will be performed by Nursing staff. Nurse to report to Facility Director any procedure not followed. All staff to be trained by Nurse April 25, 2011. Policy & Procedure to reflect update 4/25/11.
Person responsible for compliance - Nurse |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
Based on a review of the policy and procedure manual and an interview with the clinical supervisor and the Facility Director, the facility failed to follow their policy and procedure to document a monthly inventory of the medications.
The findings include:
On March 10, 2011, the policy and procedure manual was reviewed. Per the facility's policy and procedure, there will be a monthly inventory of medication. When documentation of the monthly inventory of the medications was requested by the licensing specialist, the facility director was unable to present this documentation for the review.
The facility director confirmed that medication inventories were not able to be located. The facility director stated that the staff member who is responsible for the completion of the medication inventories was not available and they were unable to locate the inventory documentation.
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Plan of Correction
Monthly inventory to be completed by Nurse. Inventory sheet to be kept in medication book. Director to review every three months. Meds to be kept separately per client. Ointments, orals and narcotics to be kept separate. Expired meds to be disposed of and documented. Monthly medication administration record to be completed by Nurse with all updated meds.
Person responsible to ensure compliance - Nurse |
709.51(a)(2) LICENSURE Treatment Methodology
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Treatment methodology.
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Observations
Based on the review of client records on March 11, 2011, the facility failed to ensure that clients met the criteria for admission for the inpatient non-hospital residential treatment and rehabilitation.
The findings include:
Eight client records were reviewed on March 11, 2011. Two records were from the outpatient level of care. Two of two outpatient records reviewed indicated that the clients did not meet the criteria for inpatient non-hospital residential treatment. Specifically, clients # 1 and 2 attended therapeutic groups at the inpatient level of care while they were in the outpatient program. An interview with the facility director and the clinical supervisor confirmed two clients that were in outpatient status attended groups identified for the facility's inpatient level of care.
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Plan of Correction
Staff reviewed this regulation on 4/25/11. Although these clients were alumni, outpatient and residential should not be combined for any reason and will always be involved at the treatment level based on PCPC status.
A/C Plan to include continued outpatient in county residents. Appointment to be scheduled at time of discharge and verified that the appointment was kept following the outpatient date by the Clinician.
Eligibility for Re-Entry will be determined at the time of relapse by an outside D/A provider.
Samara House alumni who are involved in the Samara House Outpatient program will no longer be permitted to attend Samara House residential groups, to be verified by the Clinician running the group.
Person responsible for compliance - Facility Director and Senior Counselor |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document a complete aftercare plan in one of one discharged outpatient record as required.
The findings include:
Two outpatient records were reviewed on March 11, 2011. One record was a discharged record and required a complete aftercare plan. The facility failed to include the criteria for re-entry into the project and contact person on the aftercare plan.
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Plan of Correction
Facility Director and Clinicians reviewed this regulation on 4/25/11. As of 4/25/11, the Senior Counselor and Facility Director will check all outpatient files to ensure compliance one week prior to discharge. This will also include criteria for re-entry into the project and contact person on the Aftercare Plan.
Person responsible for compliance - Facility Director and Senior Clinician |
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 areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with a plan of correction approved by the Department.
The findings include:
On March 10 and 11, 2011 the facility was found to be out of compliance with standard 704.11(d)(2) Annual Training Requirements and 705.25 Food Service. This area of noncompliance was also identified during the April 7 & 8, 2010 licensing inspection for which a plan of correction was submitted on April 26, 2010, 2010 and accepted and approved by the Department on April 27, 2010.
Refer to tags 704.11(d)(2) and 705.25
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Plan of Correction
Temps for refrigerator and freezer to be taken daily by Aides. Temps to remain: refrigerator - between 40 degrees F or under, freezer 0 degrees or under. Cold and hot food temps to be taken as prepared on daily menu. Hot food temp to be maintained at 140 degrees F. All temps to be recorded and kept in a log book. Cold/hot food thermometers to be stored and kept above the sink on shelf. Aide Supervisor will review temp log book monthly. Person responsible - Nurse to oversee compliance
To prevent the further non-compliance and revokation of license, the above plan will be followed and we respectfully seek a modification/extension of training plan and plan of correction.
On-line training will be provided for the Project Director and staff due to agency cutbacks and, therefore, will make this plan achievable by June 30, 2011.
Person responsible for compliance with all employee training requirements will be the Training Coordinator, to be followed by the Facility Director. All trainings for Project Director will be approved by the Board of Directors. |