INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1, 2011 through August 2, 2011 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 the review of personnel records, staff interviews and review of training documentation, the facility failed to document four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in one of one required record.
The findings include:
Five personnel records were reviewed on August 1, 2011. One employee, specifically employee # 4, required four hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment.
Employee # 4 was hired as a counselor assistant on 2/23/2010 and was promoted to counselor on 2/23/2011. This employee was required to have four hours of tuberculosis, sexually transmitted diseases and other health related topics training by 2/23/2011. The facility failed to document four hours of required training in these topics as of the time of the inspection.
The information was requested but the staff were unable to provide the required documentation that employee # 4 attended the required training.
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Plan of Correction
Employee # 4 could not produce a certificate of training for 4 hours of TB, STD & HIV training. Therefore, she is scheduled on October 14, 2011 to go to Philadelphia for this training.
CQI/LPN will check to ensure training is completed and certificate and log placed in personnel file.
Any new Counselor or Counselor's Aide will be scheduled for training within 6 months of hire or as training becomes available.
CQI/LPN will check to ensure registration and attendance.
Anyone not complying with attendance at training will be reported to Facility Director for further action following personnel policy. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of the project director's personnel record (#1) and an interview, it was determined that the facility failed to have the project director complete at least 12 clock hours of training, as required.
The findings include:
A review of personnel record #1 was conducted on August 1, 2011. Training documentation in record # 1 indicated 3 clock hours of the required 12 hours were completed in the July 1, 2010 to June 30, 2011 training year. During an interview with the project director at 3:45 p.m. on August 2, 2011, it was confirmed that employee # 1 failed to have the required 12 clock hours of training.
This is a repeat citation from the April 7-8, 2010 licensing visit and the March 10-11, 2011 licensing visit.
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Plan of Correction
Online video training will be scheduled for staff viewing quarterly to ensure compliance. J&K Seminar Videos:
- "Treating Angry & Aggressive Children, Adolescents & Adults"
- "Healing from Loss & Abandonment"
- Treating PTSD"
- "Understanding Psychopaths"
All trainings are 12 hours each, BDAP approved.
Certificates of Completion to be printed upon viewing. Training onsite and off site to be scheduled by CQI quarterly or as available by BDAP. Review of trainings to date to be completed semi-annually for assurance.
Person responsible - CQI. |
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 review of personnel records, staff training documentation and an an interview with the Quality Assurance staff member, it was determined that the facility failed to have one of two counselors complete at least 25 clock hours of training annually.
The findings include:
Based on the review of documentation on the Staffing Requirements Summary Report, the facility's training year ran from July 1, 2010 until July 31, 2011. Two counselors were required to receive 25 clock hours of training during this time frame. The facility failed to document 25 clock hours of training in personnel record # 4. Employee # 4 had only three documented training hours for the July 1, 2010 through July 31, 2011 training year.
An interview with the Quality Assurance staff member confirmed that these were the only training hours documented in this employee's record.
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Plan of Correction
Training onsite and off site to be scheduled by CQI quarterly or as available by BDAP.
Online video training purchased, all videos are 12 hours, approved CE's:
- "Treating Angry & Aggressive Children, Adolescents & Adults"
- "Healing from Loss & Abandonment"
- Treating PTSD"
- "Understanding Psychopaths"
Review of training to date to be completed semi-annually for assurance.
Person responsible for compliance - CQI. |
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 they physical plant inspection, the staff failed to 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 findings include:
The physical plant inspection occurred on August 2, 2011 between the hours of 9:00 a.m. and 10:15 a.m. During the physical plant inspection, at 9:10 a.m. observation of the laundry room, located in the basement, revealed items that were of a hazardous nature behind the washer and dryer. There was a bed spread, sweat pants, newspaper flyers, saltine cracker packets, a plastic detergent bottle, and lint build-up behind the two washers and two dryers. Additionally, on the outside of the window where the exhaust hose leads to the outside, there was a build-up of lint on the window. The combination of various materials behind the dryers was a potential hazard to the safety of the resident, employees, and visitors of the building. Additionally, the washers had a build-up of soap detergent on the top that needed to be wiped down as well. The laundry area was not clean as evidenced by the build-up of laundry detergent on the washer, dust, and the aforementioned items behind the washers and dryers.
During the physical plant inspection of the third floor, a small entrance to an attic crawl space was observed to be unsecured. This area was accessible to staff, clients, and visitors. The temperature in this area, while not measured, was extremely hot. This room was in disarray as evidenced by various items, such as children's toys, a cooler, clothing, child-size rocking chair, etc. The unsecured area posed a potential hazard for a small child to enter the area and be exposed to excessive heat.
These finding were confirmed by the quality assurance staff member.
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Plan of Correction
As of 8/3/11, the Director of Maintenance has appointed one (1) person on each floor to check daily for any hazards on their respective floor, inclusive of the basement and laundry room to ensure cleanliness and safety. Maintenance has also been assigned to check floors and clean 2x's daily.
Person responsible for compliance - Maintenance Director.
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As of 8/2/11, a lock was secured on the door to the crawl space. Maintenance will check daily to make sure it remains locked and secured.
A smoke detector was installed in this area on 8/2/11.
Person responsible for compliance - Maintenance Director. |
705.5 (j) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(j) A residential facility shall prohibit smoking and use of candles in bedrooms.
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Observations
Based on the physical plant inspection, the facility failed to ensure that a residential facility prohibited smoking and use of candles in bedrooms.
The findings include:
A physical plant inspection took place on August 2, 2011 between the hours of 9:00 a.m. and 10:15 a.m. Three candles were observed in client bedroom # 7.
The Clinical Supervisor and Quality Assurance staff member confirmed this finding.
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Plan of Correction
As of 8/2/11, candles were removed (although not burnt). All clients and staff have been informed that no candles are permitted - even unlit. This requirement has been added to room checklists that occur daily.
Person repsonsible for compliance - Lead Counselor's Aide; CQI will oversee. |
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 an inspection of the physical plant and an interview with the quality assurance staff member, the facility failed to ensure frozen food was stored at or below 0 F.
The findings include:
The kitchen was inspected on August 2, 2011. Per regulation, a residential facility that operates an onsite food preparation area or a central food preparation area shall keep frozen food at or below 0 F. The facility had two chest freezer and two refrigerator/freezer units available for use. The temperatures were reviewed in all units. The thermometer in the chest freezer #2 located in the dining room read 19 F which exceeded 0 F. A temperature log was reviewed for freezer #2 and there were documented freezer temperatures between 19 F and 26 F.
The quality assurance staff member was interviewed on August 2, 2011 and confirmed this finding.
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Plan of Correction
Freezers to be checked daily by Counselor's Aides. Temperature to remain at 0 degrees or under. All temps to be recorded and kept in log book, located in Nurse's office. Aide Supervisor will review log book monthly.
Person responsible - Nurse. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on observation, a review of the policy and procedure manual, and staff interview, the facility failed to follow their policy on limiting smoking to designated smoking areas.
The findings include:
The facility policy and procedure manual was reviewed on August 1, 2011. According to the policy and procedure manual, Samara House has a "No Smoking Policy Pro-Children's Act of 1994". The policy states, " The CYWA will adhere to a "No smoking policy" due to the Pro-Children's Act of 1994. Specifically, smoking is not permitted in any area of the building where children services are rendered. Designated smoking areas to only include:
1. 1st Floor/CYWA patio for Staff, Community Members, visitors, and shelter residents with use of proper receptacles.
2. 3rd Floor/Samara House patio for Staff and Samara House Residential Program Participants with use of proper receptacles.
No smoking signs were observed on the exterior of the building to advise staff, visitors, and residents that smoking is not permitted in the building.
On August 1, 2011 at 3:30 p.m,. employee # 1, the project director, was observed smoking in the facility in the location of her office. The facility director of Samara House was in the office with the project director at the time of this finding. The project director and facility director both confirmed this finding.
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Plan of Correction
As of 8/2/11, the Project Director is no longer smoking in the office and is smoking only in designated smoking areas, which would include outside patio area. Signs will be posted stating hours patio cannot be used for smoking when children are in the area, which would be during after school hours 4pm to 6pm or during summer day camp hours from 7am to 6pm.
Person repsonsible for compliance - Maintenance & Building Safety Director.
A verbal warning will be given to anyone breaking this policy and the procedures for "Drug Free Workplace" will be followed. |
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 observation during the physical plant inspection, the facility failed to maintain each ramp, interior stairwell and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inc drop with a well-secured railing.
The findings include:
The physical plant inspection took place on August 2, 2011 between the hours of 9:00 am and 10: 15 am. At approximately 9:20 am it was observed that there were two sets of three steps that did not have a well-secured railings. On the main set of stairs leading from the first floor to the second floor, three steps leading to a landing failed to have a well-secured railing. Additionally, on this same staircase, there are three steps leading to a landing to the third floor that failed to have a well-secured railing.
The project director confirmed this finding.
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Plan of Correction
Two (2) 4-foot sections with two (2) brackets each will be installed to both landing staircases using like materials. to be completed by 9/15/2011.
Person responsible for compliance - 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 observation during the physical plant inspection, the facility failed to maintain protective caps over each electrical outlet.
The findings include:
The physical plant inspection was conducted on August 2, 2011 between the hours of 9:00 a.m. and 10:15 a.m. It was observed in client bedroom # 16 that two electrical outlets failed to have three of four required protective caps.
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Plan of Correction
Safety caps are checked three (3) times daily and are sometimes removed by clients. We will be ordering model # 10406 swivel caps that help prevent removal, as they are screwed in. They will be purchased, shipped and installed by 9/30/11. Staff on duty will continue to check outlets 3 times daily to ensure security and safety.
Person responsible for compliance - Staff on duty and Maintenance Director.
We recently purchased entire stock of safety swivel outlet covers, 17 are installed in high usage areas as a test. As they have held up well, we will be ordering and installing 102 more to use in all common areas of the building and all of Samara House. As they are back ordered and take three (3) weeks to get, this will be completed by September 30, 2011. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on physical plant inspection of the facility and an interview with the Facility Director, the facility failed to have the fee schedule posted for outpatient services in a prominent place.
The findings include:
On August 2, 2011 a physical plant inspection was conducted. At 10:15 am, it was observed that the facility failed to have the fee schedule posted for outpatient services in a prominent place. The Facility Director confirmed that the fee schedule was not posted.
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Plan of Correction
Signs posted on 8/2/11. Staff to check monthly to ensure signs remain posted on Counseling Outpatient door and in the lobby. Signs now state - Do Not Remove.
Person responsible for compliance - Clinical Supervisor. |
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 the review of client records, the consent to release information forms to the funding sources exceeded 4 Pa. Code Subsection 255.5 (b) in 1 of 5 client records.
The findings include:
Based on the review of records on August 2, 2011, the facility failed to ensure that information disclosed to a probation office did not exceed 4 Pa Code Subsection 255.5 (b). In client record # 3 there was a directive in a progress note, documented on 7/13/2011, to send a copy of the client's discharge summary to the Probation Office. The discharge summary included information that exceeded the permissible information to the probation officer: whether the client is or is not in treatment, client's prognosis, the nature of the project, a brief description of the client's progress, and a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
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Plan of Correction
Clinical Supervisor met with Clinicians and reviewed 255.5(b) regulations and posted disclosures for this regulation above desk and a Supervisory Note was written and placed in the personnel file as of 8/25/11.
Clinical Supervisor and CQI to check files monthly and Director to check files monthly to ensure regulation compliance.
Facility Director to follow up with staff if there is any non-compliance and follow disciplinary actions as outlined in personnel policy. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on review of the facility policy and procedure manual, client medication records, and an interview with staff, the facility failed to document medication refusals in two of two required records.
The findings include:
The policy and procedure manual was reviewed on August 1, 2011. According to the facility policy and procedure manual, "any medication errors will be recorded including when a client refuses or misses medication." The facility failed to follow their policy for client # 7 and 8.
Client # 7 was prescribed Seroquel, 200 mg tablet, to be taken at 6 p.m. The facility failed to document the reason the client failed to take their medication on August 1, 2011 at 6 p.m.. This client was also prescribed Amphetamine Salts, 20 mg tablet, taken orally twice daily at 8 a.m. and 2 p.m. The facility failed to document the reason the client failed to take their medication on August 1, 2011 at 8 a.m.
An interview with the facility nurse confirmed that staff did not document the client's refusal to take medication or missed medication doses.
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Plan of Correction
All staff reviewed policy and procedure on August 3, 2011.
Med book review is done daily in the a.m. to ensure meds are signed out by staff and client, or that med was refused or missed, all with proper documentation.
Person responsible for compliance - CQI/LPN.
If med is refused or missed more than three (3) times, the doctor is to be notified and the med to be discharged and disposed of or a new script given.
Person responsible for compliance - CQI/LPN.
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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 the review of the facility policy and procedure manual, facility tour, and an interview with the Quality Assurance Staff/Nurse, the facility failed to keep refrigerated drugs stored in a designated refrigerator for medications.
The findings include:
The policy and procedure manual was reviewed on August 1, 2011. According to the policy on storage areas, " Prescribed drugs will be kept in their original containers within the facility's designated medical office and maintained in a locked cabinet. Refrigerated drugs (are) to be stored in a designated refrigerator." Based on observation during the physical plant inspection, a refrigerated chemotherapy medication was found in the refrigerator designated for staff food items. There was a separate refrigerator specifically for client medications, however, the staff failed to place this medication in the designated refrigerator for medications.
An interview with the Quality Assurance Staff/Nurse confirmed that the facility failed to follow their policy.
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Plan of Correction
Meds will be disposed of if med is discontinued or expired. Medication Disposal Sheet to be completed and filed.
All refrigerated meds will be checked daily and locked in the med refrigerator.
Person responsible for compliance - CQI/LPN. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on August 2, 2011 the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one client records.
The findings include:
Six client records were reviewed on August 2, 2011. Five records were from the inpatient level of care. Of these records, three records were discharged client records. One record required written notification to the client informing him/her of the decision to terminate the client's treatment. The facility failed to document notification to the client in client record # 3. The notification of termination was missing the second page which included the client's signature and date to verify that the client was notified of the therapeutic discharge.
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Plan of Correction
As of 8/25/11, Clinical Supervisor and CQI/LPN stapled blank termination forms together so as to have both pages when notice is given to clients of termination. Original copy is in the program manual.
At the time of termination notice, the Clinical Supervisor and CQI will ensure compliance with forms. Facility Director to oversee for compliance as well. Any non-compliance issues will be dealt with by following personnel policy.
A Clinical Staff Meeting was held on 8/25/11 to discuss the regulation and review the 2-page document.
Persons responsible for compliance - Clinical Supervisor, CQI and Facility Director. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision terminating treatment in one of one client records.
The findings include:
Six client records were reviewed on August 2, 2011. Five records were from the inpatient program. The project was required to give the client an opportunity to request reconsideration of a decision terminating treatment in one client record. The project did not document that the client was given an opportunity to request reconsideration in client record # 3. The notification of termination was missing the second page which included the client's right to appeal the facility's decision to involuntarily terminate client # 3's treatment.
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Plan of Correction
As of 8/25/11, Clinical Supervisor and CQI/LPN stapled blank termination forms together so as to have both pages when notice is given to clients of termination. The Right to Appeal is on the 2nd page.
Original copy is in the program manual. At the time of termination notice, the Clinical Supervisor and CQI will ensure compliance with forms. Facility Director to oversee for compliance as well. Any non-compliance issues will be dealt with by following personnel policy.
A Clinical Staff Meeting was held on 8/25/11 to discuss the regulation and review the 2-page document.
Persons responsible for compliance - Clinical Supervisor, CQI and Facility Director. |
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 the facility's policy and procedure manual, client records, and interview with clinical supervisor, the facility failed to document follow-up in two of three required records.
The findings include:
Seven client records were reviewed on August 2, 2011. Six records were from the inpatient program of which three were discharged records, that required follow-up documentation, specifically records # 2, 3, and 4. According to the facility policy and procedure manual, "Samara House does perform short-term follow-up activities designed to insure continuity of care and effectiveness of our referral mechanisms. Within one week of the client's discharge the Program Director will contact the outpatient aftercare providers to ensure the client's attendance as scheduled. In the event the client has failed to attend the scheduled appointment, the counselor will attempt to contact the client. An additional telephone contact will be made 90 days after (following) completion of treatment. The client will be asked how she is doing in areas of employment, housing, and substance abuse. Referral for services will be made, if necessary. These contacts will be documented in the client record as well as in the Follow-up Log. In those cases where a client has left Against Staff Advice or been Therapeutically Discharged, every attempt will be made by the Primary Therapist to follow normal Aftercare Planning and Follow-up Procedures."
Client # 2 was admitted on 5/11/2011 and was discharged on 5/26/2011, leaving against facility advice. There was documentation that the client was contacted; however, the documentation failed to document a date that the contact was made. Therefore, it could not be determined whether the facility followed their policy.
Client # 4 was admitted on 1/11/2011 and ws discharged on 6/24/2011. According to the client's aftercare plan they had an outpatient appointment on 7/7/2011. Follow-up documentation was required by 7/14/2011 to determine whether or not the client made the appointment. There was no follow-up documented in this client record.
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Plan of Correction
Within one (1) week of client discharge, assigned staff will call to ensure attendance as scheduled. Documentation of date will be on follow-up log. Additional contacts will be made and documented at 90 days. Clinical Supervisor and CQI will check log to verify information of date, contact and time.
Persons responsible for compliance - Clinical Supervisor and CQI. |