INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26. 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on March 26, 2026, the facility failed to ensure fire extinguishers are inspected and approved annually by local fire department or fire extinguisher company.The fire extinguisher in the first-floor great room did not have a tag on it, indicating when it was last inspected. Additionally, the fire extinguisher in the hallway of the third floor was last inspected in November of 2024.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Description of Corrective Action Taken
- The fire extinguisher located in the first-floor great room was immediately removed from service on March 27, 2026, due to the absence of an inspection tag.
- A certified fire extinguisher service company was contacted, and the extinguisher was inspected, tagged, and approved on April 23, 2026.
The fire extinguisher located in the third-floor hallway, last inspected in November 2024, was identified as overdue and was serviced, inspected, and re-tagged on April 23, 2026
- All fire extinguishers throughout the facility were reviewed to ensure compliance.
2. Plan to Prevent Recurrence
- The facility has implemented a Fire Safety Compliance Log to track inspection dates for all fire extinguishers to be managed by the Maintenance Supervisor.
- A contract has been established with a certified fire extinguisher company to perform annual inspections and tagging in accordance with regulatory requirements.
- The Maintenance Supervisor will perform monthly internal checks to verify:
o Presence of inspection tags
o Valid inspection dates
o General operability (pressure gauge, accessibility, etc.)
3. Person(s) Responsible
- The Project Director is responsible for overall compliance and will meet with the Maintenance Supervisor monthly.
- The Maintenance Supervisor is responsible for:
o Scheduling annual inspections
o Maintaining documentation
o Conducting monthly checks
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4. Timeframe for Completion
- All corrective actions were completed on April 23, 2026.
- Ongoing monitoring procedures (monthly checks and annual inspections) are effective immediately and continuous.
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5. Monitoring and Quality Assurance
- Monthly fire extinguisher inspections will be documented in the Fire Safety Compliance Log.
- Documentation will be reviewed quarterly by the Project Director to ensure continued compliance.
- Any extinguisher found inoperable will be repaired or replaced within 48 hours, per regulation.
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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 a physical plant inspection on March 26, 2026, the facility failed to ensure that all electrical outlets, within the facility, had protective caps over them. An outlet in the kitchen was missing protective caps.This is a repeat citation from the April 10, 2025, annual licensing renewal inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Description of Corrective Action Taken
- On March 26, 2026, the uncovered electrical outlet located in the kitchen was immediately fitted with an approved protective cap.
- A same-day full facility sweep was conducted to inspect all electrical outlets in client-accessible and childcare areas.
2. Plan to Prevent Recurrence
- Due to this being a repeat citation, the facility has implemented enhanced corrective measures:
o A daily Environmental Safety Checklist was created to include verification that all electrical outlets have intact protective caps to be conducted by Residential Tech,
o Protective outlet caps will be maintained in on-site inventory and maintained by the Lead Residential Tech to allow for immediate replacement if any are missing or damaged.
o Staff have been retrained on child safety standards, with emphasis on environmental hazards and regulatory compliance requirements.
o The Maintenance Supervisor will conduct and document weekly environmental rounds to track and correct any deficiencies in a timely manner.
3. Person(s) Responsible
- The Facility Director is responsible for ensuring overall compliance and oversight.
- The Maintenance Supervisor is responsible for:
o Conducting weekly inspections
o Maintaining supply of outlet covers
o Ensuring immediate correction of deficiencies
- All direct care staff are responsible for reporting missing outlet caps immediately to the Lead Residential Tech for replacement.
4. Timeframe for Completion
- Immediate corrective actions were completed on March 26, 2026.
- Preventative measures, including staff retraining and implementation of weekly checks, were completed by March 31, 2026.
- Ongoing monitoring is continuous.
5. Monitoring and Quality Assurance
- Weekly environmental safety checks will be documented and reviewed by the Facility Director.
- Monthly supervisory audits will be conducted by the Facility Director to ensure sustained compliance.
- Findings will be incorporated into the facility's Quality Assurance/Performance Improvement (QAPI) process.
- Any future deficiencies will be corrected immediately upon discovery.
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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.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven records reviewed.Client #4 was admitted on May 12, 2025 and was discharged on June 23, 2025. Staff members contacted an adult probation officer on June 10, 2025; however, there was no release of information documented in the record prior to the disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Description of Corrective Action Taken
- The record for Client #4 was reviewed in full. It was confirmed that staff contacted the Adult Probation Officer on June 10, 2025 without a documented, valid Release of Information (ROI) on file at that time.
- As the client has already been discharged, a late ROI could not be obtained; however, the incident was documented internally.
- The facility conducted an immediate audit of all active client records to ensure that valid, signed ROIs are present prior to any external communication. Any missing or incomplete ROIs were immediately addressed with current clients.
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2. Plan to Prevent Recurrence
- The facility has implemented the following systemic changes:
o A mandatory ROI verification step has been added to the admission and ongoing documentation process. No external communication may occur without a completed and signed ROI in the record.
o An ROI checklist will be included in each client chart to ensure proper authorization is obtained, including:
Specific entity/person authorized
Purpose of disclosure
Expiration date
Client signature and date
o A paper record will include a clearly labeled section for ROI documents to ensure visibility and accessibility for staff.
o Staff are now required to document presence of ROI prior to any disclosure by phone or in writing.
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3. Person(s) Responsible
- The Lead Counselor is responsible for oversight of clinical documentation and confidentiality compliance.
- The Facility Director is responsible for ensuring policy implementation and enforcement.
- All clinical and direct care staff are responsible for verifying the presence of a valid ROI prior to any disclosure of client information.
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4. Timeframe for Completion
- Immediate record audit and corrective actions were completed by March 30, 2026.
- Staff retraining and implementation of revised procedures were completed on April 5, 2026.
- Ongoing compliance measures are effective immediately and continuous.
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5. Monitoring and Quality Assurance
- The Residential Tech/File Clerk will conduct monthly chart audits to verify the presence of valid ROIs prior to documented external communications.
- Findings will be reviewed as part of the Quality Assurance/Performance Improvement (QAPI) process.
- Any identified deficiencies will result in immediate corrective action and staff re-education.
- Compliance trends will be tracked and reviewed quarterly in Staff Meeting.
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6. Staff Training
- All staff received mandatory retraining on confidentiality regulations and HIPAA/42 CFR Part 2 requirements, with emphasis on:
o Obtaining informed and voluntary consent
o Proper completion and storage of ROIs
o Prohibition of disclosure without authorization
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of residential treatment and rehabilitation client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included an aftercare plan prior to discharge, per facility policy, in one of two applicable client records reviewed.Client #5 was admitted on August 1, 2025 and was discharged on November 6, 2025. An aftercare plan was not documented in the client record prior to the client ' s discharge.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Description of Corrective Action Taken
- The record for Client #5 was reviewed and confirmed to be missing a documented aftercare plan prior to discharge on November 6, 2025.
- As the client has already been discharged, a retroactive aftercare plan could not be completed; however, the omission was documented internally.
- An immediate audit of all current clients was conducted to ensure that aftercare plans are completed prior to discharge. Any client nearing discharge without a documented aftercare plan was addressed immediately.
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2. Plan to Prevent Recurrence
- The facility has implemented the following corrective system changes:
o A mandatory discharge planning protocol requiring completion of the aftercare plan prior to discharge, with no exceptions.
o A Discharge Checklist has been implemented and must be completed and signed by clinical staff before a discharge can occur. The checklist includes:
Completed aftercare plan
Referrals and appointments documented
Client acknowledgment/signature (when applicable)
o The aftercare plan process will begin early in treatment and be reviewed and updated throughout the client's stay.
o The client record will include a designated section for aftercare planning to ensure visibility and compliance.
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3. Person(s) Responsible
- The Lead Counselor is responsible for oversight of clinical documentation and discharge planning compliance.
- The Case Manager is responsible for:
o Developing and documenting the aftercare plan
o Ensuring completion prior to discharge
- The Facility Director is responsible for enforcement of policy and overall compliance.
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4. Timeframe for Completion
- Immediate corrective actions and record audit were completed by March 30, 2026.
- Implementation of the discharge checklist and updated procedures was completed by April 5, 2026.
- Ongoing compliance is effective immediately and continuous.
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5. Monitoring and Quality Assurance
- The Residential Tech/File Clerk will conduct monthly chart audits, specifically reviewing discharged client records to ensure aftercare plans are present and completed prior to discharge.
- The Lead Counselor will review discharge documentation at the time of discharge to ensure compliance in real time.
- Results will be incorporated into the facility's Quality Assurance/Performance Improvement (QAPI) program.
- Any deficiencies will result in immediate corrective action and staff retraining.
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6. Staff Training
- All clinical staff have received retraining on discharge planning requirements, including:
o The importance of aftercare planning for continuing of care
o Regulatory requirements under DDAP
o Proper documentation standards and timelines
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of residential treatment and rehabilitation client records and the project's policies and procedures manual, the project failed to document a complete client record on an individual that included a follow-up contact note within seven days of discharge, per facility policy, in two of four applicable client records reviewed.Client #6 was admitted on October 14, 2025 and was discharged on November 6, 2025. A follow-up contact note was not documented in the client record at the time of the inspection.Client #7 was admitted on November 13, 2025 and was discharged on February 21, 2026. A follow-up contact note was not documented in the client record at the time of the inspection.This is a repeat citation from the April 14, 2023, April 4, 2024, April 10, 2025, and March 26, 2026, annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Description of Corrective Action Taken
- Records for Client #6 and Client #7 were reviewed and confirmed to be missing documented follow-up contact within seven days of discharge.
- As both clients had already been discharged, staff made immediate follow-up attempts by phone upon discovery. These attempts were documented in the client records.
- An audit of all discharged clients within the past 30 days was completed to identify any additional missing follow-up documentation. Any identified gaps were addressed and documented accordingly.
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2. Plan to Prevent Recurrence
Due to the repeated nature of this citation, enhanced systemic changes have been implemented:
- A mandatory Follow-Up Tracking System has been established:
o All discharged clients are entered into an After-Care Follow-up log with a due date (within 7 days post-discharge).
- A Discharge & Follow-Up Checklist is now required and includes:
o Scheduled follow-up contact date
o Assigned staff responsible for contact
o Documentation verification field
- An additional staff has been added to the Follow-up contact responsibilities. This task is now assigned to the Case Manager and Residential Tech.
- The facility has implemented a calendar reminder system to alert staff of upcoming follow-up deadlines.
- Lead Counselor must verify completion of follow-up documentation weekly.
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3. Person(s) Responsible
- The Case Manager and Residential Tech are responsible for oversight of compliance with follow-up requirements.
- The Case Manager and Residential Tech are responsible for:
o Completing follow-up contact within 7 days.
o Documenting all attempts and outcomes in the client record
- The Facility Director is responsible for enforcement and accountability due to repeat deficiencies.
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4. Timeframe for Completion
- Immediate corrective actions and follow-up attempts were completed by March 30, 2026.
- Implementation of the tracking system, checklist, and staff assignment process was completed by April 5, 2026.
- Ongoing monitoring is effective immediately and continuous.
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5. Monitoring and Quality Assurance
- The Facility Director will conduct weekly reviews of the follow-up tracking log to ensure all discharged clients receive timely follow-up.
- Monthly chart audits will be performed by the Residential Tech/File Clerk verify that follow-up documentation is completed within the required timeframe.
- Compliance will be reviewed as part of the Quality Assurance/Performance Improvement (QAPI) program.
- Due to repeated citations, progressive corrective action will be taken for staff non-compliance, including retraining and disciplinary action if necessary.
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6. Staff Training
- All clinical staff have completed mandatory retraining on:
o Follow-up requirements per DDAP regulations
o Facility policy requiring contact within 7 days of discharge
o Proper documentation standards for follow-up attempts and outcomes
- New staff will receive this training during orientation, and competency will be documented.
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7. Administrative Oversight (Repeat Citation Response)
- Given the history of repeated non-compliance, leadership has increased oversight by:
o Incorporating follow-up compliance into staff performance evaluations
o Reviewing trends quarterly to ensure sustained compliance
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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 client records and administrative information, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for documenting a complete client record on an individual that included a follow-up contact note was submitted and approved by the Department for the April 14, 2023, April 4, 2024, April 10, 2025, and March 26, 2026, annual licensing renewal inspections. Documenting a complete client record on an individual that included a follow-up contact note, was again found to be a deficiency in the March 4, 2026 through March 5, 2026, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Statement of Noncompliance Acknowledgment
The facility acknowledges that it failed to consistently implement and sustain compliance with previously approved Plans of Correction related to documenting follow-up contact notes within required timeframes. Despite prior corrective actions and approvals, deficiencies were again identified during the March 4?5, 2026 inspection cycle.
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2. Immediate Corrective Action Taken
- An immediate internal compliance audit was conducted on all discharged client records to verify completion of required follow-up contact documentation.
- Missing or late follow-up contacts identified during the audit were:
o Completed where possible (within allowable scope)
o Properly documented as late entries when applicable
- All active discharge procedures were placed under temporary heightened supervisory review to ensure compliance pending full corrective system implementation.
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3. Systemic Root Cause Analysis
The facility identified the following contributing factors:
- Inconsistent assignment of responsibility for follow-up contacts after discharge
- Lack of real-time tracking or centralized monitoring system
- Insufficient supervisory verification prior to record closure
- Ineffective prior corrective action implementation and monitoring
- Staff misunderstanding of accountability for post-discharge documentation requirements
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4. Corrective Actions to Ensure Compliance
To ensure sustained compliance with all previously approved Plans of Correction, the facility has implemented the following system-wide corrections:
A. Centralized Follow-Up Tracking System
- A master discharge follow-up log has been implemented to be maintained by the Facility Director.
o Increase in staff to assist with follow-up responsibilities.
o Due date for follow-up (within 7 days)
o Completion verification status
B. Mandatory Discharge Accountability Process
- No client file may be considered complete or closed until:
o Follow-up contact is documented
o Lead Counselor has reviewed and signed off
- A Discharge Packet Checklist is required for every client.
C. Supervisory Oversight Enhancement
- The Residential Tech/File Clerk must conduct weekly audits of all discharged clients.
- Compliance results are reported to the Facility Director.
D. Policy Revision and Enforcement
- Facility policy has been revised to explicitly state:
o Follow-up contact is a mandatory, non-optional discharge requirement
o Failure to complete documentation constitutes a policy violation subject to corrective action
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5. Staff Training and Competency Validation
- All clinical and direct care staff completed mandatory retraining on:
o DDAP follow-up documentation requirements
o Discharge procedures and timelines
o Documentation standards and accountability expectations
- Staff competency will be validated through:
o Post-training review
o Chart audit performance monitoring
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6. Responsible Parties
- Lead Counselor: Oversight of documentation compliance and clinical discharge processes
- Facility Director: Enforcement of corrective actions and regulatory compliance
- Case Manager and Residential Tech: Completion of follow-up contacts and documentation within required timeframe
- Quality Assurance: Ongoing auditing and reporting of compliance trends
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7. Timeframe for Implementation
- Immediate corrective actions and audits completed by: March 30, 2026
- System implementation (tracking log, checklist, policy updates): April 5, 2026
- Staff retraining completed by: April 7, 2026
- Full ongoing compliance monitoring: Effective immediately and continuous
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8. Monitoring and Quality Assurance Plan
- Weekly review of discharge follow-up logs by supervisory staff
- Monthly chart audits of discharged clients for compliance verification
- Quarterly reporting through the facility's Quality Assurance/Performance Improvement (QAPI) process
- Immediate corrective action for any identified deficiency, including retraining and disciplinary measures if necessary
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9. Assurance of Sustained Compliance
The facility acknowledges the repeated nature of this citation and affirms that the above system-level interventions are designed to ensure ongoing compliance with all previously approved Plans of Correction and DDAP regulatory requirements.
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