INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Samara House of CYWA was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, it was discovered that Employee #3, who was hired as a counselor on March 22, 2021, did not meet the educational requirements to be a counselor. At the time of the hire, the employee had an Associate ' s of Arts in General Education, which is a non-qualifying degree for the position of counselor.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
To meet the DDAP requirements for the position of Counselor, the facility hired a full-time Master's Level Counselor on June 24th, 2021. Her Master's degree is in counseling and she will begin employment on July 12th, 2021. Additionally, on June 23rd, 2021, the facility hired a part-time Counselor Assistant. She will begin employment on June 28th, 2021.
To further be in compliance with DDAP requirements for the position of Counselor, the present full time Counselor was placed in the position as a Counselor Assistant as she was unable to obtain her transcripts and she will be closely supervised by the Clinical Supervisor/Facility Director. |
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
Based on the review of the fire drill logs, the facility failed to maintain a written fire drill record that included the problems encountered and whether the fire alarm or smoke detector were operative in all fire drills conducted from May 2020 through May 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 3rd, 2021, The Project Director created a form to document all problems encountered, which has been placed in the facility's Fire Drill Log.
On the first of each month the Maintenance Staff will contact The Protection Bureau to request a copy of our fire/smoke alarm monitoring system report. Any noted deficiencies will be reported to the facility and corrected by either Maintenance Staff or by the alarm company. |
709.28 (c) 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.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.Client #1 was admitted on December 22, 2021 and was a current client at the time of the inspection. There was documentation that staff, the client and the client ' s probation officer held a telephone meeting on April 26, 2021; however, there was no informed and voluntary consent form signed by the client prior to the disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
To assure that all clients have a consent of release signed prior to any phone conversations being conducted on in person meetings, the Counselor will first meet with the client to complete any necessary releases. Also, The Facility Director along with the Project Director will conduct a weekly auditing of the client charts Case Management Notes to assure that we are in compliance to the regulation of client confidentiality. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four of seven client records reviewed.Client #1 was admitted on December 22, 2020 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan documented on January 28, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented for the weeks of April 4, 2021 through April 10, 2021, April 18, 2021 through April 24, 2021, April 25, 2021 through May 1, 2021, May 9, 2021 through May 15, 2021 and May 16, 2021 through May 22, 2021.Client #2 was admitted on November 23, 2020 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan documented on November 31, 2020, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented for the weeks of March 21, 2021 through Mary 27, 2021, April 11, 2021 through April 17, 2021 and May 2, 2021 through May 8, 2021.Client #3 was admitted on February 19, 2021 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan documented on February 19, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented for the weeks of March 14, 2021 through March 20, 2021 and March 21, 2021 through Mary 27, 2021.Client #5 was admitted on February 19, 2021 and was discharged on May 10, 2021. A comprehensive individual treatment and rehabilitation plan documented on February 23, 2021, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented for the weeks of March 21, 2021 through March 27, 2021.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
It will be the responsibility of the Facility Director to assure that all clients have their weekly individual counseling session with their assigned counselor. Each counselor will post on their office doors along with giving the client the date and time that their weekly individual counseling session is scheduled to occur.
Additionally, the Project Director and Facility Director will complete a weekly audit of the Client's Counseling Record to assure that these weekly individual treatment sessions are happening. |