INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 30-31, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Samara House of Cywa was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on interviews conducted during a complaint investigation, the facility failed to follow the Code of Conduct policy and procedures. Per the Code of Conduct, people are to be treated with dignity and respect in all circumstances and staff who violate the code of conduct may be subject to disciplinary action, including termination of employment.Incidents of intimidation, disrespect and bullying was reported to have been inflicted on clients by staff, up to and including those in leadership positions. There have been no consequences allotted to the staff in leadership positions pertaining to their not following the facility Code of Conduct.
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Plan of Correction
Effective 1/5/23 All Samara House Staff was mandated to complete the following trainings: Bullying Prevention-completed 1/5/23: Review of Code of Conduct and Respect and Dignity Policies-completed 2/8/23: Professional Conduct/Best Practices-completed 3/25/23: Ethics- completed 3/25/23. Effective 2/1/23 The Project/Facility Director has established facilitating a bi-weekly all staff meeting. During these meetings the Code of Conduct and Respect and Dignity Policies will continue to be reviewed with all staff over the next 3 months. As apart of the onboarding process of New Hires, the Code of Conduct and Respect and Dignity Policies will be reviewed and signed by new employees. New Hires will also be required to complete the Bullying Prevention and Professional Conduct/Best Practices trainings during the 7-day orientation period. Effective 05/09/23 the Grievance Policy was updated to state that the Program Assurance Liaison (PAL) will receive all grievances submitted by clients. The grievance will be reviewed together with the Program Director within 24 business hours to derive a solution and determine course of action regarding any needed consequences for involved staff members, including staff in leadership positions, that have violated these policies. The Program Assurance Liaison will meet with the client within 48 business hours to review the results of the grievance. After the results are reviewed with the client, the Program Assurance Liaison will mark the grievance "complete" and file in the Grievance Log.
Effective 5/9/23 the Grievance Policy was updated.
If a grievance is against the Program Assurance Liaison, the grievance will be submitted directly to the Project/Facility Director. The Project/Facility Director along with the Program Director will meet to derive a solution and determine course of action regarding any needed consequences . The Project/Facility Director along with the Program Director will meet with the client within 48 business hours to review the results of the grievance. After the results are reviewed with the client, the Project/Facility Director will mark the grievance "complete" and file in the Grievance Log.
If a grievance is against the Program Director, the grievance will be submitted directly to the Executive Director. The Executive Director along with the Project/Facility Director will meet within 24 business hours to derive a solution and determine course of action regarding any needed consequences. The Executive Director along with the Project/Facility Director will meet with the client within 48 business hours to review the results of the grievance. After the results are reviewed with the client, the Project/Facility Director will mark the grievance "complete" and file in the Grievance Log. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on Department staff observation of an event at the facility requiring the presence of ambulance personnel, the facility failed to notify the Department of this unusual incident within the regulatory three business day timeframe. An incident occurred on 3/30/23 which involved ambulance personnel being called to the facility. This occurred during the complaint investigation, while Department staff was on site. The facility did not submit an unusual incident report to the Department about this event within three business days.
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Plan of Correction
Effective 5/10/23 It will be the responsibility of the Lead Counselor Aide to receive all Samara House Incident Reports. The Lead Counselor Aide will be responsible for ensuring that the Project/Facility Director receives the incident report the same day or next business day. It will be the responsibility of the Project/Facility Director to review the Samara House Incident Report and to determine if the incident falls under the DDAP Regulations of reportable incidents. Once determined, it will be the responsibility of the Project/Facility Director to transfer the details of the incident onto the DDAP Unusual Incident Report Form and submit within 72 business hours after the incident occurred. Once sent, It will be the responsibility of the Project/Facility Director to ensure that the completed form is placed in the Program Assurance Liaisons secure mailbox for filing in the Unusual Incident Report Log.
On 3/31/23 the Project/Facility Director followed the protocol of reporting Unusual Incidents to DDAP. On 3/31/23 the Unusual Incident Form was completed, sent to DDAP and then filed in the Unusual Incident Report Log.
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709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of client charts, incident reports since January 2023 and staff interviews, the facility failed to inform the Department of unusual incidents involving an outbreak of a contagious disease requiring CDC notification within the regulatory three business day timeframe.Documentation in client files showed that clients had COVID 19 and were quarantined in their rooms on 1/31/23 and on 2/10/23. The facility did not submit Unusual Incident Reports to the Department to communicate this.This finding was reviewed with facility staff during the investigation.
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Plan of Correction
Effective 5/10/23 It will be the responsibility of the Counselors, Case Managers, Counselor Assistant, Counselor Aides and/or Lead Counselor Aide to document unusual incidents on the Samara House Unusual Incident Report Form and to place it in the secured mailbox of the Lead Counselor Aide. The Lead Counselor Aide will be responsible for ensuring that the Project/Facility Director receives the Samara House Unusual Incident Report the same day or next business day. It will be the responsibility of the Project/Facility Director to review the Samara House Unusual Incident Report and to determine if the incident falls under the DDAP Regulations of reportable incidents. Once determined, it will be the responsibility of the Project/Facility Director to transfer the details of the incident onto the DDAP Unusual Incident Report Form and submit within 72 business hours after the incident occurred. Once sent, It will be the responsibility of the Project/Facility Director to ensure that the completed form is placed in the Program Assurance Liaisons secure mailbox for filing in the Unusual Incident Report Log.
On June 1, 2023, the Project/Facility Director will transfer the details from the 1/31/23 and 2/10/23 Covid-19 Outbreak from the Progress Notes in the clients chart onto the Unusual Incident Report. The Unusual Incident Report will be faxed to DDAP on June 1, 2023 then filed in the Unusual Incident Report Log.
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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 document treatment plan updates within the regulatory time frame in two out of seven client records reviewed.Client # 5 was admitted on 8/15/22 and discharged on 11/28/22. A treatment plan update was completed on 9/23/22 and the next update was due no later than 10/23/22; however, there was no update documented in the record at the time of the investigation. Client # 6 was admitted on 10/21/22 and discharged on 2/9/23. A treatment plan update was completed on 12/28/22 and the next update was due no later than 1/28/23; however, there was no update documented in the record at the time of the investigation. This finding was reviewed with facility staff during the investigation.
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Plan of Correction
Effective 5/10/23, it will be the responsibility of the Program Assurance Liaison to perform weekly Clinical Chart Audits. The areas of focus for these audits will be Tx Planning, Tx Plan Updates, Individual Counseling, Risk and Bio Assessments. It will be the responsibility of the Program Assurance Liaison to document on the Clinical Chart Audit Form any areas, such as Tx Plan Updates, that don't meet the parameters of the Time Line. It will be the responsibility of the Program Assurance Liaison to place a copy of the Clinical Chart Audit Form in the Project/Facility Directors secure mailbox for follow-up. It will be the responsibility of the Project/Facility Director to review the deficiencies from the Clinical Chart Audit with the Counselor. It will be the responsibility of the Counselor to correct the deficiency and place the corrected documentation in the "To be Filed Folder" for filing within 24 hours. |
709.17(a)(8) 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:
(8) Mistreating or abusing individuals cared for or treated by the facility.
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Observations
Based on interviews conducted during a complaint investigation, the facility was found to have mistreated or abused individuals cared for or treated by the facility. Per the Code of Conduct, people are to be treated with dignity and respect in all circumstances and staff who violate the code of conduct may be subject to disciplinary action, including termination of employment. Per the Treating Clients with Respect and Dignity policy, client concerns will be addressed in a non-judgmental fair and dignified manner and clients will not be retaliated against if a complaint is filed. Clients will not be bullied, yelled or cursed at or called derogatory names. Staff will not abuse power or authority when delivering services.Various incidents were communicated by ten out of thirteen individuals interviewed. Interviewees reported Incidents of intimidation, disrespect and bullying to have been inflicted on clients by staff, up to and including those in leadership positions. These incidents include clients being threatened with discharge and loss of housing referrals if a complaint is filed, clients being degraded in groups and staff abusing power by communicating misinformation to outside agencies as mandatory reporters. It was also reported grievances regarding employees in leadership roles are not being communicated to the governing body.
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Plan of Correction
Effective 1/5/23 All Samara House Staff was mandated to complete the following trainings: Bullying Prevention-completed 1/5/23: Review of Code of Conduct and Respect and Dignity Policies-completed 2/8/23: Professional Conduct/Best Practices-completed 3/25/23: Ethics- completed 3/25/23. Effective 2/1/23 The Project/Facility Director has established facilitating a bi-weekly all staff meeting. During these meetings the Code of Conduct and Respect and Dignity Policies will continue to be reviewed with all staff over the next 3 months. As apart of the onboarding process of New Hires, the Code of Conduct and Respect and Dignity Policies will be reviewed and signed by new employees. New Hires will also be required to complete the Bullying Prevention and Professional Conduct/Best Practices trainings during the 7-day orientation period. Effective 05/10/23, during the all staff bi-weekly meeting facilitated by the Project/Facility Director along with the Interim Executive Director and the Program Director, the Code of Conduct and Respect and Dignity Policies were reviewed. During this meeting staff was reminded that clients are not to be retaliated against if a complaint is filed and that services are to be delivered in a non judgmental manner without abuse of power or authority. The Program/Facility Director also reviewed, that clients shall not be bullied, yelled or cursed at or called derogatory names. Staff was reminded that failure to comply with these policies will result in disciplinary action including termination of employment. An acknowledgement receipt was signed by all staff and placed in the Staff Meeting Minute Log. It will be the responsibility of the Program Assurance Liaison to audit the Staff Meeting Log bi-weekly for completion. |