INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 23, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations against Samara House of CYWA were substantiated. 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 complaint investigation:
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on interviews with clients and staff, the facility failed to ensure that clerical and other support staff were employed in sufficient numbers to guarantee efficient and safe operations of all of the services provided by the project.
The findings include:
Eight clients and two staff persons were interviewed during the on-site complaint investigation completed on April 23, 2014. Clients and staff reported insufficient security was provided at the facility. Men were observed on two separate occasions on the third floor where the women and children are located. The first time, a man was observed on the floor during overnight hours. The second time, a man was observed on the floor during the morning hours when the clients were at the methadone clinic.
The Project Director confirmed the findings during an exit interview via telephone on April 28, 2014.
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Plan of Correction
The overnight shift person was originally to be the Program Assurance Liaison to assist with CQI and clerical. That position has been changed, as of May 15, 2014, to be a Counselors Aide position to provide more interaction with clients and children and to ensure safety. Buzzers have also, as of May 15, 2014, been secured to Samara House doors to ensure notification that someone is entering Samara House. If an issue of safety occurs at the facility, contact will be made with the local police department first, then reported immediately to the Facility Director and Project Director.
Persons responsible for compliance are CQI, Facility Director and Project Director. |
704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
Based on interviews with clients, it was determined that the facility failed to demonstrate awake staff coverage 24 hours a day.
The findings include:
An on-site complaint investigation was conducted at the facility on April 23, 2014. During the interviews with clients, it was reported that the overnight staff on duty had been observed sleeping on numerous occasions. Additionally, during an interview with the Facility Director, she acknowledges that on some occasions it happens, but they can't always prove it.
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Plan of Correction
Memorandum was issued on 5/15/2014 to all overnight staff by Facility Director reinforcing the overnight staff positions are awake positions per State Reg 704.3(d) 24 Hour Coverage. Anyone reported sleeping by staff will be investigated by Facility Director, if founded, will follow disciplinary action as stated in the Staff Handbook. (1) verbal warning (1st offense), (2) written warning (2nd offense), (3) termination. All information will be placed in the individual's personnel file.
Facility Director will make unannounced calls and visits to Samara House to ensure memorandum is being followed, beginning 6/2/14.
Persons responsible for compliance are Facility Director and CQI-LPN.
Person responsible for compliance is Facility Director.
To begin May 16, 2014. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, the facility failed to ensure the facility grounds were in good repair.
The findings include:
Based on observations during the physical plant inspection conducted on April 23, 2014, it was noted that the ceiling tile in the third floor hallway, between bedrooms 15 and 16 had water stains and was bowed. While the tile was dry at the time of the inspection, it was reported by staff that if it rains hard enough, the ceiling would leak.
The Project Director confirmed the findings during the exit interview via telephone on April 28, 2014.
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Plan of Correction
The source of the leaks is the roof. A grant for $175,000 has been secured from the Chester County Department of Community Development (DCD). Architects and Engineers are completing the Bid Package. It is estimated that the project will take four (4) to six (6) months, including the publishing of the offer, a pre-bid meeting, distribution of the Scope of Work, receiving proposals, ensuring the selection of a contractor with the skill set to accomplish the task expediously at a reasonable cost, the award of the contract and the completion of the project.
Date of completion - The area where the roof is leaking will be repaired by June 15, 2014, which is separate from the time frame for the complete replacement of the roof which is scheduled to be completed by November 23, 2014
Persons responsible for compliance are Project Director/Executive Director and Chester County Housing Representative.
As of 6/2/2014, Maintenance will check ceiling daily in Samara House, as well as daily on staff of Samara House. Any leaking, damage or safety issues will be reported immediately by Work Requeest and taken care of immediately. If outside contractors need to be consulted, this will be done immediately as well.
Persons responsible Project Director, CQI and Maintenance. |
705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on the physical plant inspection, the facility failed to provide bathrooms which included toilet paper and paper towels or a mechanical dryer to accommodate staff, residents, and other users of the facility.
The findings include:
Based on observations during the physical plant inspection conducted on April 23, 2014, it was noted that the facility failed to provide paper towels or a mechanical dryer for client, staff, and visitor use in four out of five bathrooms. Additionally, the facility also failed to provide toilet paper for client, staff, and visitor use in four out of five bathrooms.
The Project Director confirmed the findings during the exit interview via telephone on April 28, 2014.
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Plan of Correction
Paper towels and toilet paper, as of May 15, 2014, will be issued 1x monthly. CQI will check supply, if low, will buy and be reimbursed by finance. We will look into feasability of purchasing hand blow dryer.
Persons responsible for compliance are CQI and Facility Director. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on the physical plant inspection as well as interviews with staff and clients, the facility did not have an operable dishwasher to ensure all eating, drinking and cooking utensils are properly sanitized after each meal.
The findings include:
Based on observations during the physical plant inspection conducted on April 23, 2014, as well as interviews with staff and clients, it was noted that the dishwasher was inoperable for at least six weeks and they were concerned that dishes do not get properly sanitized before being used again.
During a phone call with the Project Director on April 28, 2014, she reported that the dishwasher was broken and a new one had been purchased approximately six weeks ago, however, it had not yet been installed.
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Plan of Correction
Dishwasher will be installed by June 10, 2014.
Person responsible for compliance is Project Director.
As of June 2, 2014, staff from Samara House will fill out a maintenance request if the dishwasher is not working properly. It will be checked immediately by maintenance. If needed a technician will be called or the dishwasher will be replaced following Request for Funds being submitted to the Finance Department.
Persons responsible for compliance are Project Director and Maintenance Department. |
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 the results of staff and client interviews as well as documentation presented to Division staff at the time of the inspection, the facility failed to ensure that it was free of rodent and insect infestation at all times.
The findings include:
Eight clients were interviewed during the onsite complaint investigation conducted on April 23, 2014. The client interviews verified that there had been an issue with cockroaches in the facility. One client reported that the cockroaches had been an issue since she had been admitted to the facility, however, she has not seen any cockroaches recently. Additionally, invoices dated 1/28/14, 2/25/14, and 3/27/14 from a pest control contractor were reviewed. The invoices verified the pest control company had been in to lay down glue traps and glue boards.
A phone call with the Project Director occurred on 4/28/14 where she confirmed they had been dealing with an on-going cockroach problem but pest control had been out in March to remedy the situation.
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Plan of Correction
As of May 12, 2014, there will be a continuation of monthly rodent control treatment by outside contractor.
Person responsible for compliance is Project Director.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on interviews with staff and clients, the facility failed to assure support services were being provided in accordance with the individual treatment and rehabilitation plan.
The findings include:
Eight clients and two staff persons were interviewed during the on-site complaint investigation completed on April 23, 2014. Of the ten individuals interviewed, two clients and one staff person reported that there have been missed medical appointments due to the van driver not showing up for scheduled shifts. Additionally, clients and staff reported that at times the clients have had to walk back and forth to the methadone clinic, which is located 1.5 miles from the facility, because the van driver is inconsistent and is not always on time and/or does not show up at all. A phone call with the Project Director on April 28, 2014 confirmed there had been two occasions where clients were unable to make it to scheduled appointments due to the driver not showing up.
The Project Director confirmed the findings.
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Plan of Correction
The Facility Director and Project Director/Executive Director met with the Transport Driver on May 12, 2014 to explain 709.52 Regulation and to assure support services are continuously provided, inclusive of transport to appointments. Back-up part-time driver has been hired and all residents upon admission must register with Rover - the local transport for individual appointments that are scheduled in advance. Driver was informed to call 2 hours ahead if unable to come in so as to allow time to call substitute driver.
Person responsible for compliance will be CQI. Any failure in compliance will be reported to Facility Director for investigation.
To begin as of May 12, 2014.
As of 6/2/14, substitute driver and back-up substitute driver are both local and are on call for emergency transport when full-time driver gives notice. If neither substitute can make it, existing staff on duty will ensure floor coverage and provide transport to appointment.
Persons responsible for compliance are CQI and Facility Director.
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