INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection and complaint investigation conducted on June 20, 2019 and June 21, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection on June 20th, 2019 and June 21st, 2019, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:Upon entering the facility through the front door, it was observed that the brick retention wall was crumbling and in need of repair. There were several bricks missing from the wall and lying in the grass next to the wall.A section of drywall ceiling in the basement room that was previously a daycare area is cracked, exposing a hole.The external gate outside of the emergency exit is in need of repair as it did not latch properly.The middle stairwell was missing a banister midway up the stairs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/22/19 the Maintenance Assistant repaired the missing bricks and disposed of all damaged bricks and reinforced retention wall.
On 6/22/19 the Maintenance Assistant repaired the hole in the drywall in the basement, previously the facility daycare.
On 6/22/19 the Maintenance Assistant installed new latch.
On 6/22/19 the Maintenance Supervisor installed banister on middle stairwell midway up the stairs.
The Maintenance Supervisor will conduct a daily walkthrough of the building interior and exterior.
As of 7/16/19 an inspection checklist has been created to be completed daily by the Maintenance Supervisor. The checklist will include the building interior & exterior, systems, dwelling (walls, ceilings, floors), all bathrooms & kitchen (will ensure hot water temp doesn't exceed 120F and removal of any clogs in sinks or toilets), electricity, plumbing, HVAC, Cabinetry, Security (locks on doors, exits, outlets covered, all entrances, exits and doorways free of obstruction) health and safety (smoke detectors, fire exits, fire extinguishers, stairways, protective caps on electrical outlets), Windows, Appliances, garbage disposal/removal, leaks, gutters, chimney, foundation, control rodent and insect infestation.
This list will be reviewed daily with the Facility Office Administrator to determine the order and priority of any needed repairs.
Person Responsible: Maintenance Supervisor, Facility Office Administrator
Compliance: 7/16/19
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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 a physical plant inspection on June 20, 2019 and June 21, 2019, it was observed that the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair for the safety and well-being of residents, employees and visitors as evidenced by the following:A liquid substance was on the 1st floor kitchen creating a potential fall hazard.Paint was peeling from the ceiling in multiple areas of the 1st floor kitchen. One specific area was over the sanitizing sink.The hand washing sink was being held up by a wooden dowel in the 1st floor kitchen.Linoleum was chipped near the 1st floor kitchen stairway, exposing the subflooring. The light fixture in the 1st floor kitchen did not have a lightbulb installed, therefore exposing the receptacle.The plaster was missing/chipped around the basement emergency exit exposing foam and the interior of the wall.Garbage, debris and fruit-flies were in the basement leading to the emergency exit.Condensation was on the basement floors making the floors slippery and unsafe.The concrete basement stairwell was missing the metal plate on one of the steps; exposing the interior of the concrete. There was dirt and debris caked in the opening and is a potential entryway for insect and/or rodents.A puddle of water was in the basement storage area adjacent to the laundry room. The water was coming from the exterior of the building.In the laundry room located in the basement of the facility, both dryers contained a significant amount of build-up lint in the lint traps.Clothing was piled up behind the dryers, resting on the exhaust pipes.Tools and chemicals were in an unlocked room marked " storage area " next to the laundry room.Ceiling tile was falling, exposing the open ceiling in the clothing room.There were exposed telephone wire and outlets in 2 areas in the clothing room of the basement.Paint was peeling off the ceiling and walls in various rooms of the basement.The drain at the base of the emergency exit was missing a cover.The carpet in the middle stairwell was ripped and a tripping hazard.The door to the 3rd floor patio was broken and off the hinges. As a result, the lock on the door was not functioning properly.There was a broken green chair on the patio, exposing a sharp edge.In client room #13, the phone jack wiring was exposed. Also, in room #13, the laminate flooring was warped and chipping, exposing the subflooring. In client room # 14, there was no outlet cover, therefore exposing the interior wiring and outlet box.In client room #15, the paint in the windowsill is peeling.In client room #17, the laminate flooring is chipped, exposing the subflooring. In client room #19, the utility closet was unlocked, exposing the furnace and wiring.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/21/19 lightbulb was installed by Maintenance Assistant in 1st floor kitchen.
On 6/21/19 Maintenance Supervisor repaired and replaced plaster in basement emergency exit.
On 6/21/19 Maintenance Supervisor and Maintenance Assistant cleaned all garbage and debris in basement leading to emergency exit.
On 6/21/19 Maintenance Supervisor wiped dry condensation on the basement floor.
Maintenance Supervisor will paint basement floors with non-skid paint.
Compliance: 8/9/19
Person Responsible: Maintenance Supervisor
Maintenance Supervisor will clean dirt and debris and replace metal plate in basement stairwell.
Compliance: 8/9/19
Person Responsible: Maintenance Supervisor
Maintenance Supervisor will work along with Facility Office Administrator to assess damage and develop a repair plan of the basement storage area adjacent to the laundry room.
Compliance: 8/1/19
Person Responsible: Maintenance Supervisor, Facility Office Administrator
On 6/20/19 Maintenance Supervisor removed lint from both dryers.
On 6/20/19 Maintenance Supervisor removed all clothing from behind both dryers resting on exhaust pipes.
On 6/20/19 Maintenance Supervisor locked room marked "Storage Area" next to the laundry room.
Maintenance Supervisor will replace ceiling tile in clothing room.
Compliance: 8/1/19
On 6/21/19 Kitchen Supervisor removed liquid from 1st floor kitchen.
On 6/21/19 Food Service/Special Project Director scraped all loose paint and re-painted area over sanitizing sink.
Maintenance Supervisor will replace wooden dowel with PVC plastic legs
Compliance: 8/9/19
Maintenance Supervisor will fill all chipped linoleum with epoxy in the 1st floor kitchen.
Compliance: 8/9/19
Maintenance Supervisor will repair outlet receptacles in 2 areas of clothing room in basement.
Compliance: 8/9/19
Maintenance Supervisor will scrape all peeling paint from walls and ceiling in various rooms of the basement.
Compliance: 8/9/19
On 6/21/19 Maintenance Supervisor replaced the cover on drain at the base of emergency exit.
Maintenance Supervisor will replace carpet in middle stairwell.
Compliance: 8/9/19
On 6/22/19 Maintenance Staff replaced broken door hinges and replaced lock on 3rd floor patio door.
On 7/12/19 Program Assurance Liaison removed broken green chair from 3rd floor patio.
On 6/22/19 Maintenance Staff removed phone jack from 3rd floor room#13.
Maintenance Supervisor will replace laminate floor in 3rd floor room#13.
Compliance: 8/15/19
On 7/15/19 Maintenance Staff replaced outlet cover on 3rd floor room#14.
Maintenance Supervisor will scrape and paint windowsill on 3rd floor room#15
Compliance: 8/9/19
Maintenance Supervisor will replace flooring on 3rd floor room#17.
Compliance: 8/09/19
On 6/22/19 Maintenance Staff installed lock on utility closet on 3rd floor room#19.
The Maintenance Supervisor will conduct a daily walkthrough of the building interior and exterior.
As of 7/16/19 an inspection checklist has been created to be completed daily by the Maintenance Supervisor. The checklist will include building interior & exterior, systems, dwelling (walls, ceilings, floors), all bathrooms & kitchens (will ensure hot water temp doesn't exceed 120F and removal of any clogs in sinks or toilets), electricity, plumbing, HVAC, Cabinetry, Security (locks on doors, exits, outlets covered, all entrances, exits and doorways free of obstruction) health and safety (smoke detectors, fire exits, fire extinguishers, stairways, protective caps on electrical outlets), Windows, Appliances, garbage disposal/removal, leaks, gutters, chimney, foundation, control rodent and insect infestation.
This list will be reviewed daily with the Facility Administrator to determine the order and priority of any needed repairs.
As of 7/12/19 an inspection checklist has been created to be completed daily by Maturity Works Staff supervised by Facility Office Administrator which includes inspection and cleaning of bathrooms in basement and 1st floor (to ensure that they are clean with hand soap, toilet paper, paper towels), cleaning of 1st floor office areas, patio, lounge, kitchen (to ensure all utensils, pots and pans are in covered container), laundry room (removal of lint from dryers and debris from behind appliances).
Facility Office Administrator will receive completed checklist daily and will perform check of all areas to ensure all has been completed.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on June 20, 2019 and June 21, 2019, the facility failed to store trash, garbage and rubbish in noncombustible, covered container that prevent the penetration of insects and rodents. The lid to the trash can in the third-floor kitchen was propped up against the wall on top of the radiator rather than covering the trash can. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/12/19 the Samara House daily inspection checklist, performed 3 times a day by the Counselor Aide/Shift Lead on duty, was amended to include assuring trash can lid is properly placed on trash can.
The Samara House daily inspection checklists are turned in at the end of each shift and reviewed the next business day by the Program Assurance Liaison.
The Program Assurance Liaison will immediately report any deficiencies to the Facility Director and/or Maintenance Supervisor for corrective action or repair.
Person Responsible: The Program Assurance Liaison, The Facility Director, Counselor Aide/Shift Lead, Maintenance Supervisor.
Compliance: 7/29/19
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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 a physical plant inspection of resident bedrooms on June 21, 2019 the facility failed to prohibit smoking and use of candles in bedrooms.A cigarette butt was in room # 3.Three candles were in resident room # 11.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/16/19 the facility has implemented a strict no smoking policy. The patio outside of the Harlan Lounge has been designated as the only area where smoking is permitted. No smoking signs have been posted throughout the building and the designated area has been clearly marked by the Facility Office Administrator.
Compliance: 7/16/19
As of 7/16/19 The Facility Director has implemented a policy, which prohibits Samara House clients from having in their possession cigarettes, lighters, matches or e-cigarette devices. This policy has been placed in The Facility Policy and Procedure Manual.
On 7/23/19 The Facility Director conducted an In-service training meeting for all Samara House Staff in which this policy was reviewed. A copy was given to all Samara House staff and verification of receipt placed in personnel file.
Person Responsible: Counselor Aide on duty
Compliance: 7/16/19
As of 7/16/19 The Facility Director amended the Samara House daily room check form to assure no candles or cigarettes, lighters or matches are present in client bedrooms. This check is done 3x's a day by the Counselor Aide on duty. These forms are turned in at the end of each shift and reviewed by the Facility Director the following business day.
Person Responsible: Counselor Aide on duty
Compliance: 7/16/19
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection of the basement restrooms on June 20, 2019 the facility failed to provide an operable soap dispenser and either individual paper towels or mechanical dryers in each bathroom.The women ' s bathroom in the basement did not have an operable soap dispenser and either individual paper towels or mechanical dryers.The men ' s bathroom in the basement did not have either individual paper towels or mechanical dryers.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/12/19 an inspection checklist has been created to be completed daily by Maturity Works Staff supervised by the Facility Office Administrator which includes inspection and cleaning of bathrooms in basement and 1st floor (to ensure that they are clean with hand soap, toilet paper, paper towels), cleaning of 1st floor office areas, patio, lounge, front of building, kitchen (to ensure all utensils, pots and pans are in covered container), laundry room (removal of lint from dryers and debris from behind appliances).
Facility Office Administrator will receive completed checklist daily and will perform check to ensure all has been completed.
Person Responsible: Facility Office Administrator, Maturity Works Staff
Compliance: 7/12/19
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection of the basement bathrooms on June 20, 2019, it was observed that the facility failed to ensure that the hot water temperatures did not exceed 120 degrees.The water temperature in the basement women's bathroom was 130 degrees when tested.The water temperature in the basement men's bathroom was 129.7 degrees when tested.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/20/19 the Maintenance Supervisor corrected water temperature in both basement bathrooms at the time of inspection. Water temperature shall not excel 120F. This will be accomplished by daily walkthrough performed by Maintenance Supervisor.
The Maintenance Supervisor will conduct a daily walkthrough of the building interior and exterior.
As of 7/16/19 an inspection checklist has been created to be completed daily by the Maintenance Supervisor. The checklist will include building exterior, systems, dwelling (walls, ceilings, floors), all bathrooms & kitchens (will ensure hot water temp doesn't exceed 120F and removal of any clogs in sinks or toilets), electricity, plumbing, HVAC, Cabinetry, Security (locks on doors, exits, outlets covered, all entrances, exits and doorways free of obstruction) health and safety (smoke detectors, fire exits, fire extinguishers, stairways, protective caps on electrical outlets), Windows, Appliances, garbage disposal/removal, leaks, gutters, chimney, foundation, control rodent and insect infestation.
This list will be reviewed daily with the Facility Administrator to determine the order and priority of any needed repairs.
Person Responsible: Maintenance Supervisor, Facility Office Administrator
Compliance: Immediate (water temp to 120F) 7/16/19 Inspection Checklist Implemented
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705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection of the basement bathrooms on June 20, 2019, the facility failed to provide toilet paper at each toilet at all times.There was no toilet paper in the basement men's bathroom.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/12/19 an inspection checklist has been created to be completed daily by Maturity Works Staff supervised by Facility Office Administrator which includes inspection and cleaning of bathrooms in basement and 1st floor (to ensure that they are clean with hand soap, toilet paper, paper towels), cleaning of 1st floor office areas, patio, lounge, kitchen (to ensure all utensils, pots and pans are in covered container), laundry room (removal of lint from dryers and debris from behind appliances).
Facility Office Administrator will receive completed checklist daily and will perform check of all areas to ensure all has been completed.
Person Responsible: Facility Office Administrator, Maturity Works Staff
Compliance: 7/12/19
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection of the basement bathrooms on June 20, 2019, it was observed that the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all time.The sink in the women's bathroom in the basement was not functional due to being clogged.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/20/19 Maintenance Supervisor removed clog from women's bathroom sink located in the basement.
The Maintenance Supervisor will conduct a daily walkthrough of the building interior and exterior.
As of 7/16/19 an inspection checklist has been created to be completed daily by the Maintenance Supervisor. The checklist will include building exterior, systems, dwelling (walls, ceilings, floors), all bathrooms & kitchens (will ensure hot water temp doesn't exceed 120F and removal of any clogs in sinks or toilets), electricity, plumbing, HVAC, Cabinetry, Security (locks on doors, exits, outlets covered, all entrances, exits and doorways free of obstruction) health and safety (smoke detectors, fire exits, fire extinguishers, stairways, protective caps on electrical outlets), Windows, Appliances, garbage disposal/removal, leaks, gutters, chimney, foundation, control rodent and insect infestation.
This list will be reviewed daily with the Facility Administrator to determine the order and priority of any needed repairs.
Person Responsible: Maintenance Supervisor, Facility Office Administrator
Compliance: 7/16/19
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705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on a physical plant inspection of the first-floor kitchen on June 20, 2019, it was observed that the facility failed to clean and disinfect food preparation areas and appliances following each prepared meal. A liquid food substance on the bottom of the "Emergency Food Assistance Program Freezer."These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/20/19 Food Service/Special Project Director removed liquid /food substance from the bottom of the "Emergency Food Assistance Program Freezer".
As of 7/12/19 an inspection checklist has been created to be completed daily by Maturity Works Staff supervised by Facility Office Administrator which includes inspection and cleaning of bathrooms in basement and 1st floor (to ensure that they are clean with hand soap, toilet paper, paper towels), cleaning of 1st floor office areas, patio & front building entrance (to ensure all trash, cigarette butts are removed) lounge, kitchen (to ensure all utensils, pots and pans are in covered container), laundry room(removal of lint from dryers and debris from behind appliances), floors in all areas of basement and 1st floor will be cleaned and sanitized.
Facility Office Administrator will receive completed checklist daily and will perform check of all areas to ensure all has been completed.
As of 7/16/19 an inspection checklist has been created to be completed daily by Kitchen Supervisor and supervised by the Food/Special Project Manager. This list will include but is not limited to daily check of temperatures of all freezers and refrigerator to be recorded on log, sanitation of sink, dish and hand soap present, paper towels present, floors and all surfaces disinfected daily, no food of any kind left out, all appliances operational, trash removed, all kitchen utensils, pots, pans and dishes are put away in a clean enclosed area.
This list will be reviewed daily by the Food/Special Project Manager to ensure compliance. Kitchen Supervisor will ensure that all spills will be cleaned up immediately.
Person Responsible: Food/Special Project Manager, Facility Office Administrator, Maturity Works Staff, Kitchen Supervisor.
Compliance: 7/16/19
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705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection of the 1st floor kitchen on June 20, 2019 it was observed that the facility failed to store utensils in a clean enclosed area.A basket full of uncovered utensils was stored on the butcher block in the 1st floor kitchen.A bin full of utensils were being stored uncovered next to a mop sitting in a bucket of used dirty mop water.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/21/19 The Food/Special Project Manager removed utensils from the butcher block and stored them in the designated utensil drawer.
As of 7/16/19 an inspection checklist has been created to be completed daily by Kitchen Supervisor and supervised by the Food/Special Project Manager. This list will include but is not limited to daily check of temperatures of all freezers and refrigerator to be recorded on log, sanitation of sink, dish and hand soap present, paper towels present, floors and all surfaces disinfected daily, no food of any kind left out, all appliances operational, trash removed, all kitchen utensils, pots, pans and dishes are put away in a clean enclosed area.
Person Responsible: Kitchen Supervisor, Food/Special Project Manager
Compliance: 7/16/19
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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 a physical plant inspection conducted on June 20, 2019 and June 21, 2019, it was observed that the facility failed to keep cold food at or below 40 degrees, hot food at or above 140 degrees and frozen food at or below 0 degrees.The "Emergency Food Assistance Program Freezer" had a temperature reading of 50 degrees.Milk was observed sitting out on the counter in the 1st floor kitchen.There were no thermometers in the locked chest freezer in the basement storage area next to the laundry room or in the 2 freezers in the adjacent storage area.The temperature for the 3rd floor kitchen freezer was 11 degrees.The 3rd floor dining room freezer did not have a thermometer in it.A package of chicken and a package of beef were sitting out in the sink of the 3rd floor kitchen.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/21/19 Food/Special Project Manager installed new thermometer in "Emergency Food Assistance Program Freezer.
On 6/21/19 Milk observed on counter in 1st floor kitchen was removed by Food/Special Project Manager.
On 6/21/19 Thermometers installed by Food/Special Project Manager in the chest freezer in the basement storage area and in 2 freezers in the adjacent storage area.
On 6/21/19 Temperature was adjusted to 0 degrees in kitchen freezer on 3rd floor by Lead Counselor Aide.
On 6/21/19 Thermometer was installed in kitchen freezer on 3rd Floor by Lead Counselor Aide
On 6/21/19 Package of Chicken and Package of Beef was removed and discarded from sink in 3rd floor kitchen.
As of 7/16/19 the Maintenance Supervisor will keep on hand a total of 10 new thermometers at all times to be used if any thermometers in the facility become inoperable.
As of 7/16/19 the inspection checklist for Samara House has been amended to include daily check of temperatures of all refrigerators and freezers in Samara House 3 times a day.
On 6/26/19 The Facility Director has developed a policy that states that the Samara House Program will no longer receive donated food from the Wagon Train Program, Emergency Food Assistance Program or any other Food Donation Program. All foods to include dairy and non-perishables will be purchased at a regular food retailer or Super Market. This policy has been placed in the Facility Policy and Procedure Manual and given to all Samara House staff. The Counselor Aide, who is ServSafe Certified, has been assigned to do the monthly shopping and will check expiration dates at the time of purchase. All food entering Samara House program will be labeled and dated. Procedure for labeling leftover food as well as all other food items has been developed and reviewed with all Counselor Aides. Weekly inventory of all foods will take place during General Inspection supervised by the Counselor Aide on duty to ensure foods are rotated properly using the "First In, First Out" method to ensure no food has exceeded the expiration date.
On 8/12/19 there will be an All Staff Mandated training conducted by a ServSafe Certified individual to educate all staff on food safety, proper storage, cross contamination and time and temperature.
Person Responsible: Counselor Aide on duty
Compliance: 8/12/19
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection of on June 20, 2019 the facility failed to ensure that the facility was free of rodents and insect infestation. There were multiple dead insects in the overhead light fixture in the basement.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance Supervisor will remove all dead insects from light fixture in the basement.
Compliance: 8/9/19
The Maintenance Supervisor will conduct a daily walkthrough of the building interior and exterior.
As of 7/16/19 an inspection checklist has been created to be completed daily by the Maintenance Supervisor. The checklist will include building interior & exterior, systems, dwelling (walls, ceilings, floors), all bathrooms & kitchens (will ensure hot water temp doesn't exceed 120F and removal of any clogs in sinks or toilets), electricity, plumbing, HVAC, Cabinetry, Security (locks on doors, exits, outlets covered, all entrances, exits and doorways free of obstruction) health and safety (smoke detectors, fire exits, fire extinguishers, stairways, protective caps on electrical outlets), Windows, Appliances, garbage disposal/removal, leaks, gutters, chimney, foundation, control rodent and insect infestation
This list will be reviewed daily with the Facility Office Administrator to determine the order and priority of any needed repairs.
Maintenance Supervisor will schedule quarterly extermination.
Person Responsible: Maintenance Supervisor
Compliance: 8/9/19
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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 a physical plant inspection conducted on June 21, 2019 of the 3rd floor, it was observed that the facility failed to limit smoking to designated smoking areas.A cigarette butt was found on the floor in client room #3Multiple cigarette butts were found in the drain on the 3rd floor patio.A cigarette butt was found on the shelf of a dry erase board next to an infant's pacifier.Multiple cigarette butts were found at the front entrance of the facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/21/19 the cigarette butt was removed from client room #3 by Lead Counselor Aide.
On 6/21/19 the Lead Counselor Aide removed cigarette butts found in the 3rd floor patio drain.
On 6/21/19 the cigarette butt found on the dry erase board was removed by the Counselor.
On 6/22/19 the cigarette butts found at the front entrance of the facility were removed by Maturity Works Staff.
As of 7/16/19 the facility has implemented a strict no smoking policy. The patio outside of the Harlan Lounge has been designated as the only area where smoking is permitted. No smoking signs have been posted throughout the building and the designated area has been clearly marked by the Facility Office Administrator.
Person Responsible: Facility Office Administrator
Compliance: 7/16/19
As of 7/15/19 the Facility Office Administrator has initiated a memorandum to all CYWA Staff notifying all of the no smoking policy in the front of the building and informing staff of the designated smoke area located on the patio outside of the Harlan Lounge, side of the building.
Person Responsible: Facility Office Administrator
Compliance: 7/15/19
The Front Desk Reception/Security Staff will be responsible for ensuring that smoking doesn't take place in the front of the building. This area is monitored by video surveillance around the clock by the Front Desk Receptionist/Security Staff and Facility Office Administrator.
Person Responsible: Facility Office Administrator, Front Desk Reception/Security Staff
As of 7/12/19 an inspection checklist has been created to be completed daily by Maturity Works Staff supervised by Facility Office Administrator which includes inspection and cleaning of bathrooms in basement and 1st floor (to ensure that they are clean with hand soap, toilet paper, paper towels), cleaning of 1st floor office areas, patio & front building entrance (to ensure all trash, cigarette butts are removed) lounge, kitchen (to ensure all utensils, pots and pans are in covered container), laundry room(removal of lint from dryers and debris from behind appliances), floors in all areas of basement and 1st floor will be cleaned and sanitized.
Person Responsible: Facility Office Administrator, Front Desk Reception/Security Staff, Maturity Works Staff.
Compliance: 7/12/19
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705.9 (4) (i) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
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Observations
Based on the review of the facility's policy and procedures conducted on June 20, 2019 and June 21, 2019, the facility failed to provide a written procedure for staff and residents to follow in case of an emergency, including provisions for: The evacuation and transfer of residents and staff to a safe location. Assignments of staff during emergencies. As well as, the evacuation and transfer of residents impaired by alcohol or other drugs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/22/19 The Facility Director has implemented a policy on Emergency Evacuation and transfer of clients and staff. This policy has been placed in The Facility Policy and Procedure Manual.
On 7/17/19 The Facility Director has implemented a policy on the evacuation and transfer of residents impaired by alcohol or other drugs. This policy has been placed in The Facility Policy and Procedure Manual.
On 7/23/19 this policy will be reviewed with all staff in the mandated all staff In-Service Training Meeting. All staff will receive a copy of the Emergency Evacuation Policy and the Emergency Evacuation of residents impaired by alcohol or other drugs. A signed verification of receipt of this policy will be placed in each employee personnel file.
Person Responsible: Facility Director
Compliance: 7/23/19
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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.
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Observations
Based on a physical plant inspection on June 20, 2019, it was observed that the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.A mop was propped up against the wall outside of the 1st floor kitchen door that had the potential to fall and block the door keeping it from opening.There was an orange cone blocking the basement emergency exit to protect the truck parked outside, next to the door.Metal bowls and pots and pans were observed to be in front of the alternative emergency exit door in the basement.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/21/19 Maintenance Supervisor removed the mop propped up against the wall outside of 1st floor kitchen door.
On 6/21/19 the orange cone blocking the basement emergency exit was removed by Maintenance Supervisor.
On 6/21/19 metal bowls, pots and pans in front of the alternative emergency exit were removed by Food/Special Project Manager.
The Maintenance Supervisor will conduct a daily walkthrough of the building interior and exterior.
As of 7/16/19 an inspection checklist has been created to be completed daily by the Maintenance Supervisor. The checklist will include building interior & exterior, systems, dwelling (walls, ceilings, floors), all bathrooms & kitchens (will ensure hot water temp doesn't exceed 120F and removal of any clogs in sinks or toilets), electricity, plumbing, HVAC, Cabinetry, Security (locks on doors, exits, outlets covered, all entrances, exits and doorways free of obstruction) health and safety (smoke detectors, fire exits, fire extinguishers, stairways, protective caps on electrical outlets), Windows, Appliances, garbage disposal/removal, leaks, gutters, chimney, foundation, control rodent and insect infestation
This list will be reviewed daily with the Facility Administrator to determine the order and priority of any needed repairs.
Person Responsible: Maintenance Supervisor, Facility Office Administrator
Compliance: 7/16/19
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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 a physical plant inspection of on June 20, 2019 and June 21, 2019, it was observed that the facility failed to ensure that interior and outside stairways exceeding two steps had a well-secured handrail.A stairway leading into the 1st floor kitchen had more than more than two steps and did not have a well-secured handrail. A stairway leading into the 3rd floor dining room had more than two steps and did not have a well-secured handrail. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/10/19 handrail installed by Maintenance Supervisor in the 1st floor kitchen
On 7/10/19 handrail installed by Maintenance Supervisor leading into 3rd floor dining room.
Compliance: 7/10/19
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705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection conducted on June 20, 2019, it was observed that the facility failed to light the interior exits and stairs at all times.The interior lights leading to the emergency exit in the basement did not turn on. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/16/19 interior lights leading to the emergency exit in the basement was replaced by the Maintenance Supervisor.
The Maintenance Supervisor will conduct a daily walkthrough of the building interior and exterior.
As of 7/16/19 an inspection checklist has been created to be completed daily by the Maintenance Supervisor. The checklist will include building interior & exterior, systems, dwelling (walls, ceilings, floors), all interior and exterior lighting, all bathrooms & kitchens (will ensure hot water temp doesn't exceed 120F and removal of any clogs in sinks or toilets), electricity, plumbing, HVAC, Cabinetry, Security (locks on doors, exits, outlets covered, all entrances, exits and doorways free of obstruction) health and safety (smoke detectors, fire exits, fire extinguishers, stairways, protective caps on electrical outlets), Windows, Appliances, garbage disposal/removal, leaks, gutters, chimney, foundation, control rodent and insect infestation.
Interior and Exterior lighting throughout the facility will be checked daily by the Maintenance Supervisor effective immediately and has been added to the Building Maintenance Daily Checklist as of 7/29/19.
This list will be reviewed daily with the Facility Office Administrator to determine the order and priority of any needed repairs.
Person Responsible: Maintenance Supervisor, Facility Office Administrator.
Compliance: 7/29/19 |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
During the review of personnel records, the facility failed to document that all staff were trained in the use of the fire extinguishers upon employment. Clinical staff # 3 and # 4 were not trained for emergencies or fire extinguisher use upon hire. Additionally, all newly hired support staff were not trained for emergencies or fire extinguisher use upon hire.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has implemented a policy on Fire Extinguisher use training. This policy will be placed in the Facility Policy and Procedure Manual. All new hires will be formally trained on the correct procedure for using a fire extinguisher within 7 days of employment. New hires will also receive a handout on how to use a fire extinguisher. In addition all new hires will be required to watch an OSHA approved video. New hires will be required to sign a form, which states they have received training on fire extinguisher use. This form will be placed in the employee personnel file.
On 7/23/19 all Samara House staff will have the fire extinguisher training. All signature forms, confirming the fire extinguisher training was received, will be placed in their employee personnel file.
This training will be reviewed yearly with all Samara House staff.
Person Responsible: Facility Director
Compliance: 7/23/19
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
A review of the June 2018 through June 2019 fire drill logs was conducted during the onsite inspection. The facility failed to conduct unannounced drills during the 2018 months of August, September and October. The facility failed to conduct unannounced drills during the 2019 months of February, March and April. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
he Program Assurance Liaison will work along with the Maintenance Supervisor to assure that the facility is conducting 3 unannounced fire drills per month. A drill will occur for the morning, evening and sleeping shifts. The Facility Office Administrator has amended the Fire Drill Form to reflect all required information, time date, number of participants, pull alarm or smoke detector, route used observations. Upon completion of the drill, the Program Assurance Liaison , Maintenance Supervisor or Samara House staff on duty will complete the Fire Drill Form. The Facility Director will review on the next business day for accuracy and signature.
Person Responsible: Maintenance Supervisor, Program Assurance Liaison, Facility Director.
Compliance: 6/22/19
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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 maintain a complete written fire drill record that included the date, time, the amount of time it took for evacuation, 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. The facility did not document of the fire drill log whether the fire alarm or smoke detector was operational during the fire drills conducted in June and July 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Assurance Liaison will work along with the Maintenance Supervisor to assure that the facility is conducting 3 unannounced fire drills per month. A drill will occur for the morning, evening and sleeping shifts. The Facility Office Administrator has amended the Fire Drill Form to reflect all required information, time date, number of participants, pull alarm or smoke detector, route used observations. Upon completion of the drill, the Program Assurance Liaison , Maintenance Supervisor or Samara House staff on duty will complete the Fire Drill Form. The Facility Director will review on the next business day for accuracy and signature.
Person Responsible: Maintenance Supervisor, Program Assurance Liaison, Facility Director.
Compliance: 6/22/19 |
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
A review of the June 2018 through June 2019 fire drill logs was conducted during the onsite inspection. The facility failed to complete one unannounced fire drill during sleeping hours every 6-months. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Assurance Liaison will work along with the Maintenance Supervisor to assure that the facility is conducting 3 unannounced fire drills per month. A drill will occur for the morning, evening and sleeping shifts. The Facility Office Administrator has amended the Fire Drill Form to reflect all required information, time date, number of participants, pull alarm or smoke detector, route used observations. Upon completion of the drill, the Program Assurance Liaison , Maintenance Supervisor or Samara House staff on duty will complete the Fire Drill Form. The Facility Director will review on the next business day for accuracy and signature.
Person Responsible: Maintenance Supervisor, Program Assurance Liaison, Facility Director.
Compliance: 6/22/19
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705.11 (2) (i) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(i) Provide an interior play area which meets the developmental and recreational needs of the children in care.
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Observations
Based on a physical plant inspection conducted on June 20, 2019 and June 21, 2019, the facility failed to provide an interior play area which meets the developmental and recreational needs of the children in care.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 7/19/19 The Lead Counselor Aide along with The Maintenance Supervisor created an interior play area located on the 3rd floor of the facility. The play area meets the developmental and recreational needs of the children at Samara House. When in use this area will be supervised by the staff on duty. As a part of the daily chores done 3 times per day, the play area will be cleaned and the toys sanitized.
Person Responsible: Staff on duty
Compliance: 7/19/19
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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 a physical plant inspection conducted on June 20, 2019 and June st, 2019 the facility failed to maintain protective caps over each electrical outlet.There were no protective caps on the electrical outlet in the basement hallway.There were no protective caps on the electrical outlet in the middle stairwell.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/12/19 protective caps replaced on electrical outlets in basement hallway by Maintenance Supervisor.
On 7/12/19 protective caps replaced on electrical outlets in middle stairwell by Maintenance Supervisor.
The Maintenance Supervisor will be ordering model #10406 safety swivel caps to be installed in high usage and common areas of the building and all of Samara House. These caps are screwed in and help prevent removal. The caps will be purchased, shipped and installed by 9/1/19. The Maintenance Supervisor will check the outlet covers daily to ensure security and safety.
Person Responsible: Maintenance Supervisor
Compliance: 9/1/2019
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705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on a physical plant inspection conducted on June 20, 2019 and June 21, 2019, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks.In the basement a tool cabinet was unlocked. There were multiple sharp items used to complete yard work in the tool cabinet. In the bottom of the tool cabinet there were three old Victor brand mouse traps.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/21/19 basement tool cabinet was locked by the Maintenance Supervisor.
On 6/21/19 (3) old Victor brand mousetraps was removed from tool cabinet by the Maintenance Supervisor.
The Maintenance Supervisor will conduct a daily walkthrough of the building interior and exterior.
As of 7/16/19 an inspection checklist has been created to be completed daily by the Maintenance Supervisor. The checklist will include building interior & exterior, systems, dwelling (walls, ceilings, floors), all bathrooms & kitchens (will ensure hot water temp doesn't exceed 120F and removal of any clogs in sinks or toilets), electricity, plumbing, HVAC, Cabinetry, Security (locks on doors, exits, outlets covered, all entrances, exits and doorways free of obstruction) health and safety (smoke detectors, fire exits, fire extinguishers, stairways, protective caps on electrical outlets), Windows, Appliances, garbage disposal/removal, leaks, gutters, chimney, foundation, control rodent and insect infestation.
This list will be reviewed daily with the Facility Administrator to determine the order and priority of any needed repairs.
Person Responsible: Maintenance Supervisor, Facility Office Administrator
Compliance: 7/16/19
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705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on a review of the facility's policy and procedure manual conducted on June 20, 2019 and June 21, 2019, the facility failed to provide a written procedure for staff and clients to follow in case of an emergency that provided provisions for the evacuation and transfer of clients and staff to a safe location. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/21/19 The Facility Director has implemented a policy on Emergency Evacuation and provisions for the transfer of clients and staff to a safe location. This policy has been placed in The Facility Policy and Procedure Manual.
On 7/23/19 this policy will be reviewed with all staff in the mandated all staff In-Service Training Meeting. All staff will receive a copy of the Emergency Evacuation Policy. A signed confirmation that this policy has been reviewed will be placed in each employee personnel file.
Person Responsible: Facility Director
Compliance: 7/23/19
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a physical plant inspection conducted on June 20, 2019 and June 21, 2019, the facility failed to document any unannounced fire drills for the facility's outpatient activity between June 2018 and June 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/21/19 The Facility Director has implemented a policy on Outpatient Fire Drills. This policy has been placed in The Facility Policy and Procedure Manual. Fire Drills for Outpatient participants will be conducted once a month. The fire drills will be unannounced and documented on the newly developed fire drill log for Outpatient participants. The Facility Director will review the Fire Drill log monthly for compliance.
Person Responsible: Maintenance Supervisor, Program Assurance Liaison Facility Director
Compliance: 6/21/19
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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
Plan of Correction entered and approved 2/15/19 for 8/23/18 Onsite inspection.
To date the facility continues to be compliant.
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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
Plan of Correction entered and approved 2/15/19 for 8/23/18 Onsite inspection.
To date the facility continues to be compliant. |
709.24 (a) (4) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on the review of the facility's policy and procedure manual on June 20, 2019, it was discovered that the facility did not have a written procedures for referrals outlining cooperation with other service providers including, but not limited to, provision for access to emergency services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/16/19 The Facility Director has written and implemented an Incoming/Outgoing Referral Policy to assure that clients can be treated at our level of care. This policy will be placed in The Facility Policy and Procedure Manual. During intake assessment any clients needing additional services not provided by our facility, the assigned counselor will obtain a signed consent of release from the client and the appropriate referral will be made.
The Facility Director along with the Clinical Supervisor will ensure all Incoming/Outgoing Referrals are being completed accurately during weekly clinical meeting.
Person Responsible: Facility Director, Clinical Supervisor
Compliance: 7/16/19 |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records on June 20, 2019 and June 21, 2019, two out of four records did not contain an annual written individual staff performance evaluation.Employee #1 and #2 did not have annual written individual staff performance evaluations documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/30/19 The Project Director and The Facility Director will be on the same evaluation cycle of all Samara House employees.
Evaluations completed 6/30/19.
As of 7/29/19 The Project Director will perform yearly performance evaluation for The Facility Director. The Lead Counselor Aide/Office Administrator will review the Facility Directors personnel file yearly to ensure all pertinent performance documentation has been placed in the personnel file.
As of 7/29/19 The Board of Director President will perform yearly performance evaluation for The Project Director. The Facility Office Administrator will review the Project Directors personnel file yearly to ensure all pertinent performance documentation has been placed in the personnel file.
Person Responsible: Project Director, Board of Directors President, Facility Office Administrator, Lead Counselor Aide/Office Administator
Compliance: 7/29/19
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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
Plan of Correction entered and approved on 2/15/19 for 8/23/18 Onsite Audit.
To date the facility continues to be compliant. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records on June 21, 2019 the facility failed to keep voluntary and informed consents for the disclosure of information contained in the client record within the limits established by 4 Pa. Code 255.5 (b).Client #4 was admitted on April 29, 2019 and was still active at the time of the inspection. A voluntary and informed consent to disclose information was obtained for the client's probation officer, allowing the disclosure of the client's intake information, psychosocial assessment and treatment plan. Per 4 Pa. Code 255.5 (b), this disclosure exceeds what a probation officer is permitted to have.Client #8 was admitted on June 10, 2019 and was an active client at the time of the inspection. A voluntary and informed consent to release information was obtained for the client's probation officer, allowing the disclosure of the client's intake information, psychosocial assessment, treatment plan, discharge plan and aftercare plan. A voluntary and informed consent to disclose information for the funding source disclosed the intake information. Per 4 Pa. Code 255.5 (b), these disclosures exceeded what a probation officer and funding source are permitted to have.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will work along with the Clinical Supervisor to assure that the appropriate responses are accurately marked off on the client consent form. During the bi-weekly audit of each client treatment chart The Facility Director and Clinical Supervisor will continually monitor the accuracy of all client consent release forms.
Person Responsible: Facility Director, Clinical Supervisor
Compliance: Immediate 6/21/19
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of the project's outpatient policy and procedure manual on June 21, 2019, it was discovered that the facility did not develop written policies and procedures on client rights. There was no documented written acknowledgement by client # 8 that they had been notified of those rights. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/17/19 the Outpatient Policy and Procedure was written and completed for The Rights of Outpatient Client Participants. This policy has been placed in the Facility Policy and Procedure Manual.
On 7/23/19 The Facility Director will conduct a Mandated All Samara House Staff In-Service training meeting. All staff will receive a copy of the Outpatient Policy and it will be reviewed during In-Service Training meeting. Verification form regarding receipt of this policy will be placed in each employee personnel file.
The Client Rights for Outpatient participants will become a part of the intake packet forms. Each outpatient participant will sign that they have been made aware of their rights.
Person Responsible: Facility Director
Compliance: 7/17/19
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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
Based on the review of the project's outpatient policy and procedure manual on June 21, 2019, it was discovered that the facility did not develop and implement written policies and procedures regarding all medications used by clients. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/17/19 the Outpatient Policy and Procedure was written and completed for Outpatient Medications. This policy has been placed in the Facility Policy and Procedure Manual.
On 7/23/19 The Facility Director will conduct a Mandated All Samara House Staff In-Service training meeting. All staff will receive a copy of the Outpatient Medication Policy and it will be reviewed during In-Service Training. A verification form will be signed and placed in each employee personnel file.
The Outpatient Medication policy will become a part of the intake packet forms. Each outpatient participant will sign that they have been made aware of this policy.
Person Responsible: Facility Director
Compliance: 7/17/19
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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
Plan of Correction has been entered and approved on 2/15/19 for 8/23/18 Onsite audit.
To date the facility continues to be compliant |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on review of the facility's Medication Administration Records (MARS), on June 21st, 2019, the facility failed to document as to why clients did not receive and/or sign off on medication dosages.Client #1 is prescribed 300mg of Ursodiol; 2 capsules 2-times a day. On June 19th, 2019 and June 20th, 2019, the facility failed to document why this client did not receive and/or sign off on this medication.Client #1 is prescribed 1 capsule at bedtime of RA-Colrite. On June 19th, 2019 and June 20th, 2019, the facility failed to document why this client did not receive and/or sign off on this medication.Client #1 is prescribed 25mg of Hydroxyzine; 1 tablet 4-times a day. On June 19th, 2019 and June 20th, 2019, the facility failed to document why this client did not receive and/or sign off on this medication.Client #4 is prescribed 600mg of Ibuprofen; 1 tablet every 6-hours. On June 20th, 2019, the facility failed to document why this client did not receive and/or sign off on the client's 8:00 pm dose.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/23/19 The Facility Director conducted a Mandatory, All Samara House Staff, In-Service Training Meeting in which the Medication Dispensing Policy along with the 5 Rights of Dispensing Medication was reviewed. A copy of this policy was given to each staff member and a verification of receipt form was signed and placed in each employee personnel file.
In addition the Facility Director has amended the staff schedule to allow for 2 staff to be present during medication dispensation to assure all documentation is completed accurately and the policies for medication dispensation are being followed.
The Medical Dispensing policy will be reviewed quarterly with all Samara House Staff conducted by the Facility Director.
Person responsible: The Facility Director
Compliance: 7/23/19 |
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
Plan of Correction has been entered and approved on 2/15/19 for 8/23/18 Onsite audit.
To date the facility continues to be compliant
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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on the review of the facility's policy and procedure manual on June 20th, 2019 and June 21st, 2019, it was discovered that the facility did not develop and implement policies and procedures to respond to any of the 8 unusual incidents outlined in this regulation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/17/19 the policies and procedures were written and completed for the 8 Unusual Reportable Incidents that are to be submitted to the office of Drug and Alcohol within 3 business days. These polices have been placed in the Facility Policy and Procedure Manual.
On 7/23/19 The Facility Director will conduct a Mandated All Samara House Staff In-Service training meeting. All staff will receive a copy of each Unusual Incident Policy and they all will be reviewed during In-Service Training.
The Unusual Incident Policy will be reviewed twice a year.
Person Responsible: Facility Director
Compliance: 7/17/19
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709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on the review of the facility's policy and procedure manual on June 20th, 2019 and June 21st, 2019, it was discovered that the facility did not develop and implement policies regarding unusual incidents that included the following: (1) documentation of unusual incident, (2) prompt review and identification of the cases directly or indirectly responsible for the unusual incident, (3) implementation of a timely and appropriate corrective action plan, when indicated (4) ongoing monitoring of the corrective action plan and (5) reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/17/19 the policies and procedures were written and completed for the 8 Unusual Reportable Incidents that are to be submitted to the office of Drug and Alcohol within 3 business days. These polices have been placed in the Facility Policy and Procedure Manual.
On 7/23/19 The Facility Director will conduct a Mandated All Samara House Staff In-Service training meeting. All staff will receive a copy of each Unusual Incident Policy and they all will be reviewed during In-Service Training. Verification form regarding receipt of this policy will by signed and placed in each staff member personnel file. This policy will be reviewed twice a year.
Person Responsible: Facility Director
Compliance: 7/23/19
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the facility's policy and procedure manual on June 20th, 2019 and June 21st, 2019, it was discovered that the facility did not develop and implement policies and procedures regarding the reporting of unusual incidents; therefore, the facility failed to notify the Department within 3-day of any unusual incidents that may have occurred during this licensing period. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/17/19 the policies and procedures were written and completed for the 8 Unusual Reportable Incidents that are to be submitted to the office of Drug and Alcohol within 3 business days. These polices have been placed in the Facility Policy and Procedure Manual.
On 7/23/19 The Facility Director will conduct a Mandated All Samara House Staff In-Service training meeting. All staff will receive a copy of the Unusual Incident Policy and will be reviewed during In-Service Training meeting.
Person Responsible: Facility Director
Compliance: 7/23/19
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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
Plan of Correction has been entered and approved on 2/15/19 for 8/23/18 Onsite audit.
To date the facility continues to be compliant
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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
Plan of Correction has been entered and approved on 2/15/19 for 8/23/18 Onsite audit.
To date the facility continues to be compliant
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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
Plan of Correction has been entered and approved on 2/15/19 for 8/23/18 Onsite audit.
To date the facility continues to be compliant
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709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
During an onsite inspection on June 20, 2019 and June 21, 2019, the project failed to produce written policies for its dietetic services which included, but are not limited to: receiving, storing and preserving of food stuff. Food items in the kitchen of inpatient program failed to receive, store and preserve food stuff in a sanitary way.There were ham slices that expired May 8, 2019 in the 3rd floor kitchen.There was a large bowl of macaroni and cheese in the 3rd floor kitchen refrigerator with just a piece of foil over it. There was no date labeled on the food container.There was a large bowl of poultry in the 3rd floor kitchen refrigerator with just a piece of foil over it. There was no date on the food container.There were multiple expired and/or improperly stored food items in the personal refrigerator in the 3rd floor kitchen.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/21/19 the ham slices that expired on 5/8/19 in 3rd floor kitchen was removed and discarded by the Lead Counselor Aide.
On 6/21/19 the Lead Counselor Aide discarded the mac and cheese in the large bowl with no label in the 3rd floor kitchen refrigerator.
On 6/21/19 the large bowl of poultry covered with only the Lead Counselor Aide discarded a piece of foil in the 3rd floor kitchen refrigerator.
On 6/21/19 all expired and/or improperly stored food items were discarded by the Lead Counselor Aide.
On 6/26/19 The Facility Director has developed a policy that states that the Samara House Program will no longer receive donated food from the Wagon Train Program, Emergency Food Assistance Program or any other source. All foods to include dairy and non-perishables will be purchased at a regular food retailer or Super Market. This policy has been placed in the Facility Policy and Procedure Manual and given to all staff. The Counselor Aide (Servsafe Certified) assigned to do the monthly shopping will check expiration dates at the time of purchase. Procedure for labeling leftover food and all other food items has been developed and reviewed with all Counselor Aides. Weekly inventory of all foods will take place during General Inspection supervised by the Counselor Aide on duty to ensure foods are rotated properly using "First In, First Out" method and that no food has exceeded the expiration date.
On 8/12/19 there will be an All Staff Mandated training conducted by a ServSafe Certified individual to educate all staff on food safety, proper storage, cross contamination and time and temperature.
Person Responsible: Counselor Aide on duty
Compliance: 8/12/19
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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on an onsite inspection conducted on June 20, 2019 the facility failed to display the project's hours of operation conspicuously to the general public.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/22/19 The Facility Office Administrator has posted visibility several laminated signs to reflect the facilities hours of operation.
Person Responsible: Facility Office Administrator
Compliance: 7/22/19 |