INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9-10, 2013 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor receive at least 25 clock hours of training annually.
The findings include:
According to the Staffing Requirements Facility Summary Report, the facility training year runs from July 1st to June 30th.
Two counselors' records were reviewed for the 25 hours of training required during the 2012-2013 training year on December 9, 2013. One out of two records did not document 25 clock hours of training for the 2012 training year, specifically record # 4.
Employee #4 was hired as a counselor on October 3, 2011. Employee # 4 had only 14.5 documented clock hours of training during July 1, 2012 through June 30, 2013.
The findings were discussed with the director of facility director prior to the exit interview.
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Plan of Correction
Facilty Director and CQI personnel met on 12/30/13 with Counselor #4 to review 704.11(f)(2) Training Requirements. Staff was given a written Supervisory Suggestion to follow Training Plan for 2013-2014 or further disciplinary action will occur. #4 will be given the opportunity for approved webinars and/or local training to complete all trainings timely.
To begin January 1, 2014 and be monitored by CQI and Facility Director.
Additionally, monthly training logs will be checked by CQI; any trainings obtained will be documented, any upcoming trainings, staff will be reminded. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential 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 residents, 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 an inspection of the facility's physical plant, the facility failed to ensure the facility was in good repair at all times.
The findings include:
A physical plant inspection was conducted on December 10, 2013 at 2:40 PM. During the tour at 2:52 PM it was found that there was an electrical socket without a covering on it, which exposed the wiring in bedroom #3. This posed potential harm to the facility's residents or their children.
The findings were discussed with Nurse and the maintenance staff who were present during the physical plant inspection.
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Plan of Correction
December 10, 2013 socket was replaced. Daily room check list will include checking electrical sockets as of January 1, 2014, to be signed off by staff, CQI and Counselor Aides. CQI and Facility Director will ensure it is being followed. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential 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 an inspection of the facility's physical plant, the facility failed to provide an operable soap dispenser and paper towels in the bathrooms at all times.
The findings include:
A physical plant inspection was conducted on December 10, 2013 at 2:40 PM. During the tour, the absence of a soap dispenser and paper towels was noted in the basement bathroom. Additionally none of the client bathrooms on the second floor had paper towels during the time of inspection.
The findings were discussed with Nurse who was present during the physical plant inspection.
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Plan of Correction
December 10, 2013 CQI met with maintenance and discussed daily checks to be completed in am and pm, or as needed. CQI and Facility Director will meet with maintenance to ensure completion. CQI will perform random checks.
12/11/13 paper towels and toilet paper and hand pump soap purchased and placed in basement bathrooms. Monthly inventory (bathroom needs) to be submitted the 5th of the month, to begin January 5, 2014. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to provide toilet paper at each toilet at all times.
The findings include:
A physical plant inspection was conducted on December 10, 2013 at 2:40 PM. During the tour, the absence of toilet paper was noted in the basement bathroom and in the single bathroom on the second floor.
The findings were discussed with Nurse who was present during the physical plant inspection.
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Plan of Correction
As of 12/20/13, CQI met with staff. Bathroom checks to be completed 3 times daily to ensure toilet paper is available. As of 12/10/13 toilet paper purchased and placed in all bathrooms. Monthly inventory to be submitted every 5th of the month to begin January 5, 2014. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
A physical plant inspection was conducted on December 10, 2013 at 2:40 PM. During the tour, the women's bathroom in the basement had exposed plumbing under the left sink. The door under the right sink was hanging from it's hinges, and the bathroom appeared to not have been cleaned in a considerable amount of time.
The findings were discussed with Project Director who was present during the physical plant inspection.
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Plan of Correction
As of 12/20/13, CQI met with maintenance, new vanity to be ordered and installed by 2/6/14. Bathrooms to be cleaned by maintenance twice daily. Facility Director and CQI to ensure compliance. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on interviews with the facility's residents, the facility failed to keep the facility free of rodent and insect infestation.
The findings include:
Three residents were individually interviewed on December 10, 2013. Each was asked about the cleanliness of the environment and if they had seen signs of pests. Two out of the three clients advised they had seen roaches in the kitchen and bedroom areas on a daily basis.
Furthermore, I requested documentation of the use of pest control service from the facility director. The requested documentation was not provided to verify that the facility was making attempts at maintaining a pest-free environment for the residents and employees of the facility.
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Plan of Correction
Mike Singleton & Sons Pest Control scheduled monthly to inspect and treat building. Last visit was 12/26/13. CQI faxed previous invoice to State Inspector upon request. Samara House staff to report any rodent or insect findings immediately to maintenance. Maintenance and Finance to ensure compliance. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on the review of client records, the facility failed to document a complete client record to include aftercare plans, discharge summaries, and/or verification that work done by the client is an integral part of treatment in six out of six client records.
The findings include:
Six client records were reviewed for verification that work done by the client is an integral part of treatment on December 9, 2013. The facility failed to document the connection between the clients ' chores and their treatment in six out of six records, specifically # ' s 1, 2, 3, 4, 5, and 6.
Additionally, three out of those six client records were required to include documentation of an aftercare plan and discharge summary. The facility failed to document an aftercare plan and discharge summary in one out of three records, specifically # 6.
The treatment plans for clients #1, 2, 3, 4, 5, and 6 each included the problem statement: "Client must be consistent with chores" and a goal statement which read: "Client must complete work therapy tasks ".
However, there was no documentation of why the work therapy was an integral part of treatment for any of the clients.
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Plan of Correction
Facility Director and CQI met with staff on 12/20/13 to discuss this non-compliance (709.53) Complete Client Record. Staff trained to keep originals in client file and copy in After Care Log. Any further negligence will result in disciplinary action per personnel policies. This will be checked by CQI at time of discharge and signed by Facility Director. To begin 12/20/13.
Staff met on 12/20/13 to discuss non-compliance with 709.53 requiring treatment plans for clients 1, 2, 3, 4, and 5. A new form was created to include documentation of why work therapy was an integral part of treatment. i.e., Must maintain clean environment; healthy meal preparation creates healthy lifestyles; 3 times for chores creates daily routine and structure. To begin 12/20/13 and be checked by CQI and Facility Director. |