INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2017 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records on January 25, 2017, the facility failed to provide documentation of the required 6 hours of HIV/AIDS training and 4 hours of TB/STD training in personnel record, #4 and 5.
Employee #4, a counselor aide was hired September 8, 2011. HIV/AIDS and TB/STD training was due to be completed no later than September 8, 2013. The facility documented that employee #4 completed 6 hours of HIV/AIDS on January 13, 2016 and 3 hours of TB/STD training on May 7, 2016.
Employee #5, a program assurance liaison was hired November 1, 2001. HIV/AIDS and TB/STD training was due to be completed no later than November 1, 2003. The facility documented that employee #5 completed 6 hours of HIV/AIDS on January 12, 2016 and 6 hours of TB/STD training on May 4, 2004.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff meeting was conducted on 2/16/17 by Director. All staff reviewed 704.11 (C)(1) #4 & #5 will be scheduled for 6 hrs. HIV training & 4 hrs. TB/STD-Dept of Health approved curriculum. As will any new employees. To be completed by May 1, 2017. Certificates to be placed in personnel record. Persons responsible, Director, CQI & Program Assurance Liaison.
Facility Director and CQI/Program Assurance Liaison will check all personnel files for training & certificates to be given to Facility Director. Completed by 5/1/17. |
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 records on January 25, 2017. The facility failed to document 25 clock hours of annual training for employee #3. The facility's training year reviewed was from July 1, 2015 through June 30, 2016.
Employee #3, a counselor was hired October 3, 2011. The facility documented 21 hours of training for the training year reviewed.
These finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff meeting was held by Director on 2/16/17. All reviewed required training for counselors of 30 hrs. (usually an additional 5 hrs per Samara House) Staff requirement 704.11 (F)(2) was given to all and training plan will be initiated. Dept of Health approved curriculum. Documentation to be placed in personnel file. To be accomplished by end of training year June 30, 2017. Persons responsible Director, CQI/Program Assurance Liaison. Each given copy of requirements and training.
Facility Director to approve all trainings & training hours for the training year. Facility Director & CQI/Program Liaison will review monthly to insure compliance. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form completed by the facility and an interview with the facility director, the facility failed to ensure that staff caseloads remained at or under 8:1.
The form listed one counselor, and a facility director, as clinical staff. The facility's standard work week, as reported by the facility on the SRFSR form was 40 hours per week. However, the facility caseloads are calculated using a standard 35 hour work week.
Based on the total number of hours per week that employees #2 and 3 devoted to clients and the standard work week of 35 hours, employee #2 and 3 exceeded the allowable maximum 8:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients treatment by the facility's standard work week.
The number of hours per week devoted by employee #2 and 3 to client treatment, as reported by the facility on the SRFSR, was 48.5 hours per week. The facility reported on the SRFSR form that employees #2 and 3 had 12 active clients on December 28, 2016.
Employees #2 and 3 48.5/35 = 1.38 FTE 12 clients/1.38 FTE = 9/1 caseload
The findings were discussed with the facility director.
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Plan of Correction
As of February 1, 2017 Director has met with 2 counselors to insure FTE is carrying a caseload of 8 to 1 and PTE is carrying caseload not to exceed 4 clients. All reviewed 704.12 (a)(30)(i) regulations. Director will oversee to insure compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The fire drill record was reviewed on January 25, 2017 for the period covering January 2016 through December 2016. During that timeframe, the facility to document any fire drills during sleeping hours since February 2016.
The finding was review with facility staff during the licensing inspection.
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Plan of Correction
As of 2/16/17 Facility Director met with night security & Program Assurance Liaison to review 705.10(d)(5) fire safety to insure 1 sleep time drill every six months. Facility Director will be informed of scheduled drills to insure compliance. Drill to be scheduled by March 1, 2017.
Facility Director & CQI/Program Assurance Liaisonwill check monthly to insure fire drills are conducted 1 sleep time every 6 months. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of two outpatient client records on January 20, 2017, the facility failed to document a treatment plan update at least every 60 days in client record #11.
Client #11 was admitted on October 18, 2016 and still active at the time of the inspection. The comprehensive treatment plan was completed on October 18, 2016. The treatment plan update was due no later than December 18, 2016. The treatment plan update was documented on January 18, 2017.
These finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 2/17/17 Facility Director met with 2 counselors to review 709.92(b) treatment plan updates every 60 days to begin immediately. Facility Director will check files monthly to insure compliance for tx plan updates every 60 days. |