INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 23, 2018 by staff from the Department of Drug and Alcohol Programs. Based on the findings of the on-site inspection, Samara House of CWYA, was found to be not 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to demonstrate CPR coverage during facility hours of operation.
The facility submitted their August 2018, 24-hour work schedule and CPR certifications. The CPR documentation provided did not include the staff working the Tuesday 12 am to 8:30 am shift.
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Plan of Correction
It is the policy of Samara House that all new employees will attend an approved CPR/1st Aide class prior to beginning employment. A copy of the card will be placed in the employees personnel file and a copy of the CPR/1st Aide card will also be posted next to the staff's schedule by the Program Assurance Liaison.
The Program Director has also developed a checklist to ensure that all employees have an updated CPR/1st Aid card in their employee personnel file.
It will be the responsibility of the Program Assurance Liaison to maintain this checklist and a copy will be kept in the facilities program and procedure manual.
The checklist will be reviewed by the Program Director quarterly to maintain program and state compliance.
It will be the responsibility of the Lead Counselor Aide to ensure that every shift is covered by a CPR/First Aid certified employee.
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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
The facility failed to maintain the client to counselor ratio according to the regulation.
Facility had a ratio of 9:1 at the time of the on-site investigation.
Additionally, there were two (2) residents at the facility at the time of the investigation that were not listed on the current census bringing the total number of clients residing at the facility to fourteen (14), which is in excess of the facility's licensed capacity of twelve (12).
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Plan of Correction
The Program Director will ensure that the facility has sufficient counseling staff to adhere to the 8:1 ratio.
The Program Director will be responsible for maintaining the referral log and discharge roster. The Lead Counselor/Clinical Supervisor will provide monthly projected discharge dates to ensure no overlap of new admissions. This roster will be reviewed monthly during case consult meetings and will ensure a ratio of 8:1 is maintained by the Full-time Lead Counselor/Clinical Supervisor and a 4:1 ratio for the Part-time Counselor remains in compliance.
The Program Director will ensure that the program will not exceed licensure approved 12 clients. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to indicate whether the fire alarm or smoke detector was operational on the fire drill logs for June and July, 2018.
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Plan of Correction
The Lead Maintenance Staff and Program Assurance Liaison will be responsible for the accurate recording of all required information.
The Program Director will review, sign and date monthly to ensure program and state compliance.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to protect client confidentiality.
The facility failed to protect the clients' confidentiality by allowing individuals who are not enrolled in the residential program to spend weekends, overnight, at the facility. Additionally, the facility was also employing a current resident to answer incoming calls, which yielded client-identifying information to that individual.
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Plan of Correction
To protect the confidentiality of all clients the Program Director has developed 2 separate policies forbidding all alumni from staying overnight or staying the weekends and the other policy also prohibits clients from any employment by the Samara House/CYWA.
During the orientation process for new employees of Samara House they will receive a copy of all updated policies. Also during our monthly staff meeting all new policies will be disseminated and reviewed with all employees.
These infractions were corrected as of 8/24/18.
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709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The facility failed to ensure that medication was administered by individuals permitted by Pennsylvania law to do so.
A staff member, who is a Certified Nursing Assistant and not qualified by law according to 55 Pa Code 2380.127 to administer medication, described removing medications from prescription bottle or blister pack and handing medication to residents.
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Plan of Correction
The Program Director amended the medication distribution policy and procedure which prohibits the removal of medication from the original packaging.
An all staff meeting was conducted and the amended policy and procedure was reviewed. All staff members signed a copy of the policy and it has been placed in each employee personnel file.
During the orientation all new hires will receive a copy of the amended medication distribution policy. All policies and procedures will be reviewed on a quarterly basis for all staff members of Samara House. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
The facility failed to adhere to regulations regarding storage of narcotic medication.
The facility stored client take-home methadone in lock boxes that were kept in a single locked file cabinet drawer with keys to lock boxes in the same drawer.
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Plan of Correction
The storage of client methadone will be maintained in a locked metal cabinet within the nursing office. The keys to each client lock box will be maintained in a safe location within the Program Director's office |
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
The facility permitted individuals to reside at the facility without disclosing the facilities criteria for admission, treatment completion and discharge. Additionally, the facility failed to enroll the individual into the program.
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Plan of Correction
During the interview process of a prospected client the Program Director, Lead Counselor/Clinical Supervisor and/or Lead Counselor Aide will give an overall description of the program in its entirety.
Upon admission the assigned counselor will review the orientation process, rehabilitation phase,re-entry phase and the discharge criteria which is the completion of rehabilitation and re-entry phases, approved home plan, complete 4 family sessions by phone or face to face, final discharge planning meeting to include family, cys, probation/parole and all other interested parties. Maintain clean urines.
This procedure will be documented on the chart review checklist.
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709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
The facility permitted individuals to reside at the facility without conducting a client orientation. Additionally, the facility failed to enroll the individual into the program.
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Plan of Correction
Upon admission during the intake process The Program Director, Lead Counselor/Clinical Supervisor, Program Assurance Liaison, and Lead Counselor Aide will be a part of conducting a thorough orientation review. The client will receive a handbook, client program schedule, treatment packet work and a phone list of all service providers in the area. This process will be documented on the chart setup form. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
The facility permitted individuals to reside at the facility without having the individual to sign a consent to treatment form. Additionally, the facility failed to enroll the individual into the program.
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Plan of Correction
It will be the responsibility of the Program Assurance Liaison and the Lead Counselor/Clinical Supervisor to ensure that all intake forms are accounted for within the intake packet. During the intake process it will be the responsibility of the Lead Counselor/Clinical Supervisor to confirm that the treatment consent form has been signed and dated. The Lead Counselor/Clinical Supervisor will also sign on the chart setup form that the consent form has been completed and has been placed in the intake section of the chart.
The Program Director and the Program Assurance Liaison will review each client chart on a bi-weekly basis to ensure program and state compliancy.
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