INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 18-20, 2012 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
One personnel record was reviewed for infectious disease training on December 19, 2012. The facility failed to document the required training hours in one out of one personnel record, specifically personnel #4.
Employee #4 was hired as a counselor on October 3, 2011. Six hours of HIV/AIDS training was due by October 3, 2012. As of the date of inspection, there were only four hours of documented HIV/AIDS training for employee #4.
The findings were confirmed by the facility director prior to the exit interview.
|
Plan of Correction
CQI/LPN has scheduled HIV/AIDS Training on February 20, 2013 for employee #4. CQUI/LPN will ensure compliance with new staff hire required training through DDAP website. Website to be checked by CQI/LPN monthly for upcoming required training.
Compliance: immediate
Person responsible for compliance: CQI/LPN |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
Based on a physical plant inspection the facility failed to ensure that stairways, hallways and exits from rooms and the residential facility were unobstructed.
The findings include:
A physical plant inspection was conducted on December 19, 2012. At 3:28 PM, it was found that the exit from the gym had a chain measuring approximately 8 feet attached to the door. Although the chain was not fastened at the time, facility staff advised that the chain was in place to protect the contents of the gym at night. Once the chain is secured, the exit could not be opened, rendering it inaccessible in the case of an emergency.
The findings were observed by the Nurse Manager during the inspection.
|
Plan of Correction
On 12/19/12, at the time if inspection, the chain was removed from the gym exit door. Exits to remain unlocked and unobstructed.
Compliance: Immediate
Person Responsible: Maintenance to ensure compliance by walk through twice daily as of 1/6/2013. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of the facility's administrative documentation, the project failed to obtain an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
The project's administrative documentation was reviewed on December 18, 2012. Administrative documentation specified that the fiscal year runs from July 1 to June 30. The facility did not provide documentation of the annual financial audit for fiscal year 7/1/2010 to 6/30/2011 as of 12/21/2012.
The finding were discussed with the facility director during the entrance interview.
|
Plan of Correction
In order to ameliorate the problem regarding the lateness of our audit, we are in the process of scheduling a date now for August 2013 for our fiscal year 2012-2013. The current audit will be forwarded on or around January 31, 2013. If corrections are needed and warranted, it will delay that date by 72 hours. Oversight of this compliance is with the Executive Director and fiscal staff. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to document physical examinations in accordance with the project's policies and procedures in one of four client records.
The findings include:
In reference to the timeframe for physical exams, the facility's policy states: physical exams are to be completed within 7 days of admission into the residential program.
Four inpatient client records were reviewed for a physical examination on December 19, 2012. The facility failed to document a physical examination in one out of four inpatient client records, specifically client #3.
Client # 3 was admitted on June 5, 2012, the physical examination was due by June 12, 2012. As of the date of inspection, a physical examination had not been documented for client #3.
The findings were confirmed by the Nurse Manager on December 20, 2012.
|
Plan of Correction
Client #3's physical examination was completed by facility physician on 12/28/12.
LPN/CQI to ensure clients admitted to Samara House are scheduled for a history and physical within 48 hours to one week of admittance. Transfered clients must have release signed to obtain history and physical from prior facility, if within one year. LPN/CQI responsible to ensure compliance. CQI/LPN will check client chart bi-weekly for compliance.
Compliance: Immediate
Person Responsible: LPN/CQI |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of outpatient client records, the facility failed to document treatment plans to include the type and frequency of services in one of one client record.
The findings include:
One outpatient client record was reviewed for a treatment plan on December 20, 2012. The client record lacked documentation of a treatment plan that included the type and frequency of services, specifically client record #5.
Client #5 was admitted into outpatient treatment on November 2, 2012. The treatment plan was completed on November 30, 2012; however it did not include documentation of the type and frequency of treatment and rehabilitation services.
The findings were discussed and confirmed with the facility director prior to the exit interview.
|
Plan of Correction
Outpatient Treatment Plan form has been revised (1/7/2013) and updated to include type and frequency. LPN/CQI and Director to ensure completion once monthly.
Compliance: 1/7/2013
Person Responsible: LPN/CQI |