INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 2024, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of four personnel records, the facility failed to ensure that two of two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.Employee #3 was hired as a counselor assistant on April 28, 2023, and was still in this position at the time of the inspection. Employee #3 has a bachelor ' s degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. Close supervision is defined by regulation as " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #3 ' s personnel record only contained documented supervision once a month on October 30, 2023, September 28, 2023, August 30, 2023, July 28, 2023, June 29, 2023, May 3, 2023. There was no documented direct observation during supervision. Employee # 4 was hired as a counselor assistant on December 6, 2023, and was still in this position at the time of the inspection. Employee #4 has a master ' s degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment. Close supervision is defined by regulation as " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #4 ' s personnel record did not have documentation of weekly supervision occurring. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility/Project Director has developed a form titled "Samara House Weekly Supervision of Counselor Assistant Form" which encompasses the required supervision and observation components of counseling and to ensure that the required responsibilities of the Counselor Assistant are being performed.
It will be the responsibility of the Facility/Project Director and/or the trained counselor to meet with both Counselor Assistants weekly. 2 hours will be dedicated to case review and an additional hour of direct observation during group therapy and individual counseling sessions will be provided.
It will be the responsibility of the Facility/Project Director and/or the trained Counselor to document the results of the weekly supervision and observation on the "Samara House Weekly Supervision of Counselor Assistant Form" and to review it with the Counselor Assistant. The Counselor Assistant and the Facility/Project Director and/or the trained Counselor must sign the completed form.
It will be the responsibility of the Facility/Project Director and/or the trained Counselor to give the original signed form to the Executive Assistant weekly to be filed in the Counselor Assistants personnel file by the end of each week.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to permit heaters that were not permanently mounted or installed in the facility. Specifically, a space heater was operating in the conference room in the administrative office. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/5/24 the Maintenance Engineer completed a walk-thru of the entire agency to ensure that there were no additional space heaters in the building. On 4/5/24 the Maintenance Engineer removed all space heaters that were present out of the building. It will be the responsibility of the Maintenance Engineer to access any areas of the building that may have heating and/or cooling issues. If it is determined by the Maintenance Engineer that an additional heating and/or air conditioning source is needed then it will be the responsibility of the Maintenance Engineer to consult with a licensed HVAC Contractor to determine the appropriate wall mountable unit. On 4/5/24 the Program Director implemented this policy and procedure and has added it to the agencies Life Safety Plan. All Cywa and Samara House Employees were provided a copy of this policy and procedure. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of May 2023 through March 2024, the facility failed to prepare alternate exit routes to be used during fire drills. All exits documented were the "Primary" exit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/5/24 during the Mandatory Staff Meeting the Facility/Project Director reviewed with all staff the alternate exit routes to be used during fire drills. The evacuation procedure was updated to include the use of the alternate/secondary routes twice a month during fire drills.
It will be the responsibility of the PAL to review and sign off on the Fire Drill Log twice a month to ensure that the alternate/secondary routes are being used. The Fire Drill Log form was updated to reflect a sign line for the PAL to place there signature after the review. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document written acknowledgment by clients that they have been notified that clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. Written acknowledgement was missing in eight of eight records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/5/24 the Facility/Project Director updated client right #3 to be in alignment with DDAP Regulation 709.30 which states that the client has the right to inspect their own records and that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. On 4/5/24 all clients were been given an updated copy of the client rights and have been made aware of there right to inspect their own records and that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Each client signed a copy that was placed in the clients medical chart. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to have intake procedures that include documentation of disclosure to the client for the criteria for completion in eight out of eight records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/5/24 the Facility/Project Director created a form that encompasses the requirements for successful completion of the CYWA/Samara House Treatment Program. On 4/5/2024 the Lead Counselor Aide met with the active clients in a group setting and reviewed the criteria for successful completion. A copy was given to the clients and the clients signed a copy that was placed in the client's medical chart. On 4/5/24, this form was placed in the intake packet to be reviewed and signed by all future admissions. On 4/5/24 the criteria for successful completion was added to the client handbook. |
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 two of four applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur for successful completion 7-days, 30 days, and 60 days after discharge by phone.Client # 6 was admitted on June 23, 2023, and was discharged on August 28, 2023. A 6-month follow-up was not documented. Client # 8 was admitted on June 30, 2023, and was discharged on December 13, 2023. A 3-month follow-up was not documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/5/24 the Facility/Project Director has added an additional layer of monitoring to the client follow-up process adding the Counselor Assistants to the follow-up procedure and the CYWA/Samara House After-Care Follow-up Log to be used as a tool to keep track of the required 7-day, 3-month and 6-month follow-up dates.
It will be the responsibility of the Lead Counselor Aide to remove discharged clients from the active client list and to add them to the discharged client list and to the CYWA/Samara House After-Care Follow-up Log.
The CYWA/Samara House After-Care Follow-up Log provides a list of all discharged clients with the 7-day, 3 month and 6-month follow-up date pre-calculated.
It will be the responsibility of the Counselor Assistant and/or the Case Manager to review CYWA/Samara House After-Care Follow-up Log daily. Based on the current date the Counselor Assistant and/or the Case Manager will review the CYWA/Samara House After-Care Follow-up Log and determine if a 7-day, 3-month and 6-month follow-up is needed for any discharged client, if so, the follow call will be made, and the results of the call will be documented in the After-Care Log. |