INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 1, 2011 through August 2, 2011 licensure renewal inspection. The follow-up inspection was conducted on October 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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705.7 (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 record daily temperatures of their refrigerator and freezers.
The findings include:
The kitchen was inspected on October 7, 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 and cold food at or below 40 F . A temperature log was reviewed for all refrigerators and freezers on October 7, 2011. The facility failed to record temperatures on October 6, 2011 for all refrigerators and freezers.
The quality assurance staff member was interviewed on October 7, 2011 and confirmed this finding.
This is a repeat citation from the August 1, 2011 through August 2, 2011 licensing inspection.
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Plan of Correction
Freezers and refrigerators checked daily and documented by Counselor's Aide. Counselor's Aide Supervisor to double check daily and ensure compliance. |
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 October 7, 2011. The main set of stairs leading from the first floor to the second floor were observed to have a handrail that started/stopped at the second step. The facility failed to have a well-secured railing for the entire three stairs that were in place.
The facility director and maintenance staff confirmed this finding.
This is a repeat citation from the August 1, 2011 through August 2, 2011 licensing inspection.
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Plan of Correction
A well secured handrail will be extended to cover all three steps - completion by 10/28/11.
Person responsible for compliance: Director of Housing and Maintenance |
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 October 7, 2011. In client bedroom # 5, a power chord was observed to have four outlets without protective caps in place. Additionally, client bedroom # 18 was observed to have a wall outlet that failed to have protective caps in place.
These findings were confirmed by the maintenance staff and the quality assurance staff member.
This is a repeat citation from the August 1, 2011 through August 2, 2011 licensing inspection.
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Plan of Correction
All power cords were removed as of 10/7/11. Room checks are done daily by Counselor's Aides to ensure no power cords are in use. Outlet was replaced on 10/7/11 with new outlet that has a safety child proof feature. Aide Supervisor to check for compliance.
Person responsible for compliance: Aide Supervisor |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records and, the facility failed to document the results of a reference investigation in one of one personnel record, as required.
The findings include:
One personnel record was reviewed on October 7, 2011. Per regulation, the personnel records shall include the results of reference investigations. Based on the facility's personnel policy and procedures, after the interview, two references will be checked on the top candidate. If these references are acceptable, the candidate will be offered the position. Personnel record # 1 did not include the results of a reference investigation.
Employee # 1 was hired on October 3, 2011. There was no documentation of a reference investigation in personnel record # 1.
The facility director was interviewed on October 7, 2011 and confirmed there were no reference investigations documented for employee # 1.
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Plan of Correction
As of 10/8/2011 the Facility Director will not hire anyone until two (2) references have been contacted and are acceptable, as per the Personnel Policy.
As of 10/10/11 two (2) references were contacted and were favorable, each was documented and placed in the staff's personnel file.
Person responsible for compliance: Facility Director |
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 and client medication records, the facility failed to document medication refusals in one of two required records.
The findings include:
The policy and procedure manual was reviewed on October 7, 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 # 8 and 8.
Client # 8 was prescribed Wellbutrin 100 mg. The client was to take one tablet twice a day. The medication administration record failed to document client refusal or missed doses on the following dates: September 9, 11, 13, 15, 17, 21, 23, 25, 27, and 29, 2011. There were several blank entries that failed to include a sign-off by the client and/or staff member. The medication administration record was unclear and it was unable to be determined if the client received their dose.
Client #8 was prescribed Buspirone HCL 10 mg. The client was to take one tablet twice a day. The medication administration record failed to document client refusal or missed doses on the following dates: September 9, 11, 13, 15, 17, and 29, 2011. There were several blank entries that failed to include a sign-off by the client and/or staff member. The medication administration record did not contain documentation that specified if the client received their medication on the dates specified.
An interview with the facility nurse confirmed that staff did not document the client's refusal to take medication or missed medication doses.
This is a repeat citation from the August 1, 2011 through August 2, 2011 licensing inspection.
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Plan of Correction
Medication administration sheet has been enlarged for signatures to be legible.
Master signature sheet has been created and all staff has signed as of 10/17/11.
Staff meeting was given by the LPN with the Director and Counselor's Aides present. Verbal instruction was given on how to administer and sign out medication. Verbal warning was given at this time to all staff that if staff does not follow through termination to follow.
Group training given by LPN scheduled for 10/26/11 - Review of Policy and Procedures.
All dates should be signed and if med is refused, it must be documented in writing on the back of the MAR with staff signature and date.
Person responsible for compliance: CQI/LPN |
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 and client records, the facility failed to document follow-up in one of four required records.
The findings include:
Seven client records were reviewed on October 7, 2011. All records were from the inpatient program of which four were discharged records that required follow-up documentation, specifically record # 5. 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 # 5 was admitted on 12/21/2010 and was discharged on 6/20/2011. There was no documentation that the client was contacted for follow-up.
This is a repeat citation from the August 1, 2011 through August 2, 2011 licensing inspection.
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Plan of Correction
Counselor to make initial follow-up call for scheduled 1-week appointment with proper documentation. Counselor's Aides to continue f/u 90 days with proper documentation including date and time of call and result as per policy. Staff training on Policy and Procedures scheduled for 10/26/11.
Person responsible for compliance: Counselor's Aide Supervisor |