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 November 20, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
During an on-site provisional license follow-up inspection and complaint investigation conducted on November 20, 2019, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in one of two employee records reviewed.
Employee # 2 was hired on October 19, 2019 as a counselor and was current in that position at the time of the inspection. There was no documentation of a written individual training plan in the employee record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has developed a New Hire Initial Training Plan. It will be the responsibility of the Facility Director to assure that this form is completed within the first 7 working days after hire.
This form will be placed in the Employees Personnel File by the Facility Director.
Person Responsible: Facility Director
Completion Date: 12/13/19
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
During an on-site provisional license follow-up inspection and complaint investigation conducted on November 20, 2019, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The door to the counselor's office on the third floor was unable to be closed completely due to an obstruction blocking the door striker.
This information was shared with the facility during the inspection/investigation process.
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Plan of Correction
On November 20, 2019 the Maintenance Supervisor repaired the door knob to the Clinical Supervisors office on the 3rd floor. Checking the locks on The Counseling Office doors has been added to the Maintenance Supervisor's daily checklist to ensure all locking mechanisms are in place and not obstructed. This will assure the privacy of the client's counseling sessions are not being violated.
Person Responsible: Maintenance Supervisor
Completion Date: 11/20/19
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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
During an on-site provisional license follow-up inspection and complaint investigation conducted on November 20, 2019, the facility failed to implement their written policy and procedures regarding all medications used by clients which shall include, but not be limited to: Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
Interviews were conducted with facility staff members and current clients in regard to the procedures for medication control and administration within the facility. A result of the interviews indicated that staff were not consistently following the identified procedures related to observing clients self-administer and ensuring proper dispensing of medication. One client had been identified in diverting medication by taking extra medication out of the container at med pass as a result of facility staff not following the identified procedures.
This information was shared with the facility during the inspection/investigation process.
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Plan of Correction
On December 18, 2019 all Samara House staff will participate in a mandatory In-Service Training on all Samara House Medication Policies and Procedures. This training will be conducted by the Facility Nurse and will be reviewed with all staff quarterly.
Person Responsible: Facility Nurse
Completion Date: 12/18/19
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709.51(b)(2)(iii) LICENSURE Fee Schedule
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:
(iii) Fee schedule.
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Observations
During an on-site provisional license follow-up inspection and complaint investigation conducted on November 20, 2019, the facility failed to provide a complete client orientation to the project which includes, but it is not limited to, a familiarization with the fee schedule in three out of three client records reviewed.
Client #1 was admitted on October 7, 2019 and discharged on October 21, 2019. The client record did not have documentation of a client orientation to the project which includes, but it is not limited to, a familiarization with the fee schedule.
Client # 2 was admitted on August 2, 2019 and was still a current client. The client record did not have documentation of a client orientation to the project which includes, but it is not limited to, a familiarization with the fee schedule.
Client #3 was admitted on June 26, 2019 and discharged on November 18, 2019. The client record did not have documentation of a client orientation to the project which includes, but it is not limited to, a familiarization with the fee schedule.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
On 12/2/19 a Client Fee Schedule Form was developed by the Facility Director. This form will be reviewed with all new client admissions during the Intake Process by the Program Assurance Liaison and/or the Counselor. It will be the responsibility of the Program Assurance Liaison along with the Facility Director to assure that this form is in each client's chart during weekly chart audit.
Person Responsible: Program Assurance Liaison, Facility Director, Counselor
Completion Date: 12/2/19
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709.53(a)(7) LICENSURE correspondence
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(7) Client-related correspondence.
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Observations
During an on-site provisional license follow-up inspection and complaint investigation conducted on November 20, 2019, the facility failed to provide a complete client record to include a client correspondence with the name/organization to whom the letter was referencing in one of three records reviewed.
Client # 2 was admitted on August 2, 2019 and was still a current client. The client record had a letter that was addressed to: "To whom it may concern" and had a fax date stamp of August 23, 2019.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
It will be the responsibility of the Facility Director and/or Project Director to review all out-going correspondence ,prior to sending, to assure all correspondence contains a person's name and that a release for that person has been completed and signed.
Person Responsible: Facility Director
Completion Date: 11/21/19
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
During an on-site provisional license follow-up inspection and complaint investigation conducted on November 20, 2019 the facility failed to document a complete client record on an individual which includes information relative to the client's involvement with the project in one of three records reviewed.
Client #1 was admitted on October 7, 2019 and discharged on October 21, 2019. The client record did not contain follow-up information.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
It will be the responsibility of the Clinical Supervisor and/or the Program Assurance Liaison to follow-up with all clients who have discharged from the facility within (7) working days. This information will be documented on the Client Referral/Follow Up form and placed in the Aftercare Log.
It will be the responsibility of the Facility Director and/or Project Director to assure this process has been completed.
Person Responsible: Clinical Supervisor, Program Assurance Liaison, Facility Director and Project Director.
Completion Date: 11/21/19
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