INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 3, 2008 by staff from the Division of Drug and Alcohol 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. The following deficiencies were identified during this investigation and a plan of correction is due on December 9, 2008.
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Plan of Correction
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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 the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to safety.
Finding:
The handrail around the patio area and ramp to the sidewalk was both broken apart and loose.
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Plan of Correction
Director of Maintenance purchased metal screws to secure handrail on 11/13/08. Cement will be poured for further stability by December 15, 2008. Person responsible -- Director of Maintenance.
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The railing has been secured as of 11/13/08. Railings have been screwed together and fit securely. No rail has been left loose, no sharp edges are exposed. Between 8-10 am, the Maintenance Director and 2 Maintenance Workers will do daily checks to ensure safety and compliance. |
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 a physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to ensure the exterior of the building was free of hazards.
Findings:
The client living space on the third floor includes a balcony off of the living room where clients are permitted to spend time. Part of the exterior window looking out onto the balcony had fallen off and was lying on the balcony. The bottom half of the window sill was detached and lying on the floor of the balcony.
The gate across the stairs in the patio area, which leads down to the basement, had a missing slat. This left an opening wide enough to allow a child to get through and possibly fall down the stairs. The patio area is also the outdoor play area for the children.
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Plan of Correction
Maintenance has replaced slats that were missing on gate as of 11/4/08. Director of Maintenance to ensure building and patio safety.
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Window sill to be replaced as of 12/18/08 by Maintenance. Counselor's Aide to do daily inspection of patio door to ensure it remains locked. Director of Housing/Maintenance to ensure building and patio safety by daily checks. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to store all trash, garbage and rubbish in covered containers.
Finding:
There were three outdoor trash bins. One of three was overflowing with produce and other perishable garbage and three of three trash bins had open boxes of half rotten food stacked on the ground next to them.
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Plan of Correction
Director of Maintenance has ensured all containers have lids and a new dumpster was ordered as of 11/13/08. Person responsible -- Director of Housing/Maintenance.
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Between the hours of 9-10 am Maintenance will do daily checks to ensure lids are on the trash cans and the dumpsters are not overflowing. New dumpsters were received and are in use.
Person responsible -- Director of Housing/Maintenance. |
705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to clean and disinfect food preparation areas following each prepared meal.
Finding:
During the physical plant inspection it was noted at 10 am that the counters had not been cleaned after breakfast. There were food particles and dishes located on the kitchen countertops. The kitchen sink was overflowing with dirty dishes.
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Plan of Correction
On 11/24/08, Counselor's Aides presented Life Skills of proper clean-up after food preparation. Counselor's Aides will check chore lists to ensure each client has completed their assignments daily. Clients to clean up immediately after each meal. Persons responsible -- Counselor's Aides |
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 from 9 am to 12 pm on October 3, 2008, the facility failed to clean all eating, drinking and cooking utensils after each usage.
Finding:
There were dirty bowls on the food preparation area and the kitchen sink was overflowing with dirty dishes.
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Plan of Correction
Counselor's Aides were given a copy of State Regulations on 11/24/08. Counselor's Aides presented Life Skills on proper cleaning of kitchen and utensils. Any client not complying with chore list will be given a sanction and will be dealt with in IC session as a treatment issue. Persons responsible -- Counselor's Aides. |
705.7 (b) (5) 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:
(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 the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to keep cold food at or below 40 degrees Fahrenheit and frozen food at or below 0 degrees Fahrenheit.
Findings:
A thermometer was missing in one refrigerator and in the deep freezer. A second refrigerator had a thermometer which read 60 degrees Fahrenheit. One freezer had a thermometer which read 40 Fahrenheit. The facility failed to provide food temperature logs to indicate the food temperatures.
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Plan of Correction
Counselor's Aides will check temperature daily of freezer and refrigerator to ensure safety and licensing regulations are followed. A log will be kept daily and LPN to monitor weekly. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to maintain each ramp and outside steps with a well-secured railing.
Finding:
A metal handrail surrounds the outdoor patio area and leads down the handicapped ramp.
The metal handrail was not secured in the ground or patio and was leaning precariously. When touched, the handrail sways as if about to topple over. The handrail is cut or coming apart at the corners and was previously repaired with duct tape. The duct taped is faded and worn off and the sharp corners are exposed.
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Plan of Correction
Maintenance has repaired all railings, removed all duct tape and secured thr railing using metal screws on 11/13/08. In addition, cement will be poured by December 15, 2008. Person responsible -- Housing/Maintenance Director.
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There are no sharp metal edges exposed. The railing is secured with screws and the railing is securely put together as of 11/13/08. As of 12/9/08, the Maintenance Director and 2 Maintenance Workers will check outside patio and all other outside areas between 8-10 am daily to ensure safety and compliance. Report to be verbally given to Director and/or CQI Liaison. |
705.11 (1) (i) LICENSURE Child care.
705.11. Child care.
When a residential facility admits children for services or for custodial care, the following requirements apply:
(1) Building exterior and grounds. The residential facility shall:
(i) Fence off or have natural barriers to protect children from all areas determined to be unsafe including steep grades, cliffs, open pits, swimming pools, high voltage boosters or roads.
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Observations
Based on the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to fence off the elevated patio area which is the outdoor play area for the children
Finding:
The patio is elevated and the only barrier protecting the children from falling off is a metal handrail. The metal handrail was not secured in the ground or patio and was leaning precariously. When touched, the handrail sways as if about to topple over. The handrail is cut or coming apart at the corners and was previously repaired with duct tape. The duct taped is faded and worn off and the sharp corners are exposed. Also, a set of stairs is located on the patio where the outdoor play area is located for the children. A wooden safety gate was installed across the stairs, but one of the large wooden slats was missing, which allowed enough space for a child to climb through and fall down the stairs.
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Plan of Correction
Maintenance has repaired all railings and gates to ensure safety as of 11/13/08. Person responsible -- Housing/Maintenance Director.
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The Director of Housing/Maintenance and 2 Maintenance Workers will inspect outside areas including patio daily between 8-10 am to ensure safety and compliance. In the event that anything is broken, it will be repaired immediately. The Director of Housing/Maintenance will give report verbally daily to the Director of D/A Services and CQI Liaison beginning 12/9/08. |
705.11 (1) (ii) LICENSURE Child care.
705.11. Child care.
When a residential facility admits children for services or for custodial care, the following requirements apply:
(1) Building exterior and grounds. The residential facility shall:
(ii) Provide access to outdoor recreational space and recreational equipment.
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Observations
Based on the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to provide access to outdoor recreational equipment.
Finding:
The patio is designated as the outdoor play area for the children but at the time of the inspection there was no recreational equipment in the area.
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Plan of Correction
Donations are to be sought by the Director of Housing/Maintenance to place Playskool safe equipment on the patio for the children to play. Equipment to be in place by December 15, 2008. Person responsible -- Housing/Maintenance Director. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
Based on the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to maintain security screens or safety locks for all operable windows.
Findings:
The windows throughout the living space on the third floor were missing security screens or safety locks for the operable windows to prevent the children form opening the windows and falling out.
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Plan of Correction
All screens are in place. Safety locks have been ordered from the manufacturer and will be installed by December 15, 2008. Person responsible -- Housing/Maintenance Director. |
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 the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to maintain protective caps over each electrical outlet.
Finding:
There were missing protective caps on electrical outlets in eight out of the nineteen bedrooms inspected.
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Plan of Correction
As of 11/3/08, maintenance has purchased additional safety caps to replace any missing. Checks will be done 3 x's daily by Counselor's Aides to ensure all outlets are covered. Persons responsible -- Counselor's Aides and LPN. |
705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on the physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks.
Findings:
Laundry detergent, bleach and hydrogen peroxide was stored on the floor and/or on the dresser in bedrooms #1. Antacid was stored on the dress in bedroom #3. A cabinet with a broken lock was used to store charcoal in one of the bathrooms. Also, child safety locks were missing or broken on one third of the kitchen cabinets. Also, an oscillating fan was stored on a dresser in one bedroom; however the safety screen covering the blades was missing, which allowed children access to the blades.
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Plan of Correction
Counselor's Aides will do room checks 3 x's daily on each shift to ensure safety and no hazardous or poisonous materials and all safety locks in place on cabinets. Director to sign off room checks daily. Persons responsible -- Counselor's Aides and Director. |
705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on a physical plant inspection from 9 am to 12 pm on October 3, 2008, the facility failed to provide bathrooms to accommodate staff, clients and other users of the facility.
Findings:
A sink and a toilet in one of the client bathroom stalls were inoperable. A sign was posted on the sink and on the toilet that said "out of order."
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Plan of Correction
10/03/08 Maintenance Request Forms were completed. Bathrooms were in working order on 10/03/08. Daily checks of bathrooms will be made and working order will be maintained. Person responsible -- Samara House staff and maintenance. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of four client records on October 3, 2008, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in the client record.
Findings:
In client record #1 reviewed, the therapist documented that she spoke with a representative from the County Children and Youth office regarding the client; however there was no consent to release information signed by the client allowing for this disclosure of information.
In client record #1, the therapist documented that she spoke with a representative from the client's health insurance representative regarding the client; however there was no consent to release information signed by the client allowing for this disclosure of information.
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Plan of Correction
Since Licensing Visit, all staff have been informed to fill out and complete a Consent to Release Form to anyone the client may come in contact with. Files to be checked weekly. All staff given copies of Confidentiality and State Regulations, again. Persons responsible -- CQI and PAL. |
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 a physical plant inspection conducted from 9 am to 12 pm on October 3, 2008 and an interview with the counselor who accompanied staff on the physical plant inspection on October 3, 2008, the facility failed to follow written policy regarding drug storage areas.
Findings:
The nurse routinely is in possession of the keys to the drug storage areas. However, when the nurse is not on site, the keys to the drug storage areas are hung on a hook on the wall in the office, which is kept unlocked. Anyone who walks into this office has access to the keys hanging on the wall and therefore, has access to the drug storage areas.
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Plan of Correction
On 10/04/08 training was given to all Samara House staff by the Nurse in regards to medication administration and storage of keys and medication. Copy of Policy and Procedure given to all staff. Person responsible -- LPN, CQI and Director to check daily for compliance.
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Nurse will have keys on her person between 6 am - 2:30 pm, M-F; at 2:30 pm Counselor or Counselor's Aide will receive the keys and keep them on her person until relieved by the next shift which will continue the same until 6 am when the Nurse again receives the keys for her shift. Person responsible -- LPN, CQI and Director to check daily for compliance.
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709.32(c)(5) 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:
(5) Security of drugs.
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Observations
Based on a review of progress notes in the record for client #1, a review of policy and procedures and staff interview on October 3, 2008, the facility failed to follow written policy regarding security of drugs.
Findings:
The nurse routinely is in possession of the keys to the drug storage areas. However, when the nurse is not on site, the keys to the drug storage areas are hung on a hook on the wall in the office, which is kept unlocked. Anyone who walks into this office has access to the keys hanging on the wall and therefore, has access to the drug storage areas. Also, the facility failed to have an appropriate policy and procedure in place regarding the misuse of drugs.
Client #1 who was on methadone allowed client #2 access to her empty take home bottles. Client #2 rubbed her finger inside of the empty take home bottles to obtain methadone residue on her finger before rubbing her finger on her infant's gums.
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Plan of Correction
As of 10/04/08 we are no longer accepting take homes. Clients will continue to dose daily at ATS.
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Nurse will have keys on her person between 6 am - 2:30 pm, M-F; at 2:30 pm Counselor or Counselor's Aide will receive the keys and keep them on her person until relieved by the next shift which will continue the same until 6 am when the Nurse again receives the keys for her shift. Person responsible -- LPN, CQI and Director to check daily for compliance.
Addendum to Medication Errors and Drug Reactions, as of 12/9/08 --
Misuse of Drugs Policy to include:
- Director to be notified.
- Incident report to be completed.
- PCP to be notified and Consent documented in client chart.
- Resident and staff to be interviewed by Director of D/A.
- At no time will the resident's rights to confidentiality be violated.
Person responsible -- Nurse to do daily med checks and monthly cabinet checks. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of four client records and staff interview on October 3, 2008, the facility failed to develop an appropriate treatment plan in one of four client records reviewed.
Findings:
Based on a physical plant inspection of client #5's bedroom, there was evidence of the need for learning organizational skills. The client's bedroom had clothes and other items thrown all over the place. Personal items were piled on the floor, on the bed, and in the closet in a way in which it was impossible to walk into the bedroom without stepping on these items. During an interview with the primary counselor for client #5, the therapist noted organizational skills were built into the client's treatment plan. During a review of this client's record, the treatment plan did not address organizational skills in any way.
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Plan of Correction
As of 10/04/08 Counselors are responsible for Treatment Plan Updates and Review to be completed within 30 days of the Master Treatment Plan that is completed within 10 days of admission. Persons responsible -- CQI and Director to check files monthly for compliance.
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Monthly Case Consultations conducted with entire Samara House staff (Director, Nurse, CQI, PAL, Counselors and Counselor's Aides). Client and Counselor meet weekly for IC. IC to reflect on Treatment Plan. Person responsible -- Counselor, Director to check files once monthly, CQI to ensure compliance.
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Upon admission, clients initial needs will be addressed in Individual Sessions as the Biopsychosocial is completed. Counselors have been trained (again on 12/16/08) to assess each area's strengths and needs during Biopsychosocial, as well as to listen to the client's expression of needs. During the course of treatment, Counselors are to do Treatment Plan Updates monthly or as the need for change of treatment is indicated by the client and Counselor. Director reviews client issues, 2 x's monthly in Individual Supervisory Sessions for Counselors employed over 1 year, new Counselors 4 x's monthly, as well as throughout the course of treatment. CQI and Director responsible to monitor course of Individualized Treatment. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on a physical plant inspection on October 3, 2008, the facility failed to follow the standards regarding storing and preserving of food.
Findings:
The upright freezer located in that hallway outside of the kitchen area was broken; however, food was still being stored in it. The freezer was filled with large amounts of ice and needed to be defrosted. The door did not shut/seal properly. The facility was unable to ensure that frozen food was stored at or below 0 degrees F.
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Plan of Correction
Freezer replaced in the hallway as of 12/4/08. As of 10/05/08 thermometers have been replaced. Daily temperature checks conducted and documented daily on log by Counselor's Aides. Freezer to be GI'd on Saturdays. Responsible persons -- Counselor's Aides. CQI and Director to review logs weekly to sign off and ensure compliance. |