INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 3 -5, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Samara House of CYWA was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on November 12, 2007.
|
Plan of Correction
|
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
|
Observations
Based on a review of the physical plant conducted on October 4, 2007 at 10:30 AM. it was determined that the facility failed to maintain counseling areas with furnishings which were in good repair. A review of the physical plant conducted on October 4, 2007 at 10:30 AM revealed that the carpet in the counseling areas and hallways leading to the counseling offices were severely stained and torn from spills, burns and heavy people traffic. A discussion with the nurse who accompanied Division staff on the physical plant inspection confirmed that the carpets were recently cleaned and nothing else can be done to rid the carpet of the stains and burns.
|
Plan of Correction
Carpet in Counseling areas will be replacd by January 15, 2008.
Person overseeing the project will be the CYWA Director of Housing Development.
Hallway carpet will be replaced by March 15, 2008. Person overseeing the project will be the CYWA Director of Housing Development. |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
|
Observations
Based on a review of the physical plant conducted on October 4, 2007 at 10:30 AM. it was determined that the facility failed to ensure that each resident has a storage area for clothing.
A review of the physical plant, specifically the residential bedrooms, demonstrated that each resident did not have storage space for clothing. In addition, the children did not have storage for their clothing and other belongings, i.e. diapers, toys and shoes. Dressers in various bedrooms were missing drawer panels and hinges.
|
Plan of Correction
Four (4) dressers will be put in bedrooms by February 1, 2008.
Four (4)additional dressers to be put in bedrooms by May 1, 2008.
Four (4) chest of drawers will be placed in bedrooms by August 31, 2008.
Four (4) chest of drawers will be placed in bedrooms by November 25, 2008.
Four (4) chest of drawers will be placed in bedrooms by March 15, 2009.
Any broken furnishings will be removed.
CYWA Director of Housing Development will be responsible for compliance. |
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.
|
Observations
Based on a review of the physical plant conducted on October 4, 2007 at 10:30 AM, it was determined that the facility failed to enure that each bathroom was maintained in a functional, clean and sanitary manner at all times. A review of the physical plant revealed that the bathrooms in the residential area had used towels and washcloths hanging from various places, the trash cans were full and overflowing and individual's bars of soap were left in the showers.
|
Plan of Correction
Bathroom daily inspections will be added to Room Checklist and be conducted 3X's daily by Counselor's Aides. Bathrooms will be checked to ensure sanitary conditions, no used towels and washcloths or individual bars of soap to be left in the bathroom. Trash cans to be emptied twice daily (once in the am and once in the pm), unless need warrants being emptied more frequently. Checklists to be signed and turned in daily. Any issues with residents will be addressed in Life Skills with Counselor's Aides and/or Individual Counseling with Counselors. LPN to ensure compliance with this regulation. Effective November 15, 2007. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
Based on a review of the physical plant conducted on October 4, 2007 at 10:30 AM, it was determined that the facility failed to ensure that exits from the residential facility were unobstructed. A review of the physical plant conducted on October 4, 2007 revealed that one means of egress to the side of the building was blocked by a chair holding the door open and a mop, on the adjacent side, propped against the wall.
|
Plan of Correction
Written notice was sent on 11/8/07 to all Department Heads of the CYWA to alert all staff and supervisors that fire exits are to remain free of obstruction, inclusive of mops, buckets and chairs used for daily cleaning. Supervisors of the seniors employed in housekeeping will also reinforce to housekeeping these safety issues. The building will be checked daily. Person responsible for implementation and monitoring is the CYWA Director of Housing Development. |
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.
|
Observations
Based on a review of personnel records on October 4, 2007 it was determined that the facility failed to ensure that all staff were instructed in the use of fire extinguishers upon employment.
A review of 11 personnel records revealed that five employees, specifically #3, 4, 5, 6, and 11, were not instructed in the use of the fire extinguisher within seven days of the date of their employment. A discussion with the facility director on October 4, 2007 confirmed that employees were not instructed in the use of the fire extinguisher.
|
Plan of Correction
All staff of the CYWA will be trained by the Coatesville Fire Company on November 13, 2007 for all fire safety regulations. Training will incldue demonstration of how to use fire extinguishers with documentation of the staff that were in attendance. Anyome missing the mandated meeting will be given instruction by the Housing Development and Maintenance Director within two (2) weeks of the above date. Person responsible for ensuring completion of staff training will be the CYWA Housing Development Director. Beginning November 14, 2007, documentation of training will be done at the time of hire for each department under Training in the list of items to be in the personnel file. Administrative staff responsible for documentation for training of new staff. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records on October 4, 2007 it was determined that the facility failed to ensure that all personnel were trained to perform assigned tasks during emergencies. A review of 11 personnel records revealed that five employees, specifically #3, 4, 5, 6 and 11, did not receive training in order to perform assigned tasks during emergencies. A discussion with the facility director on October 4, 2007 confirmed that employees were not trained to perform assigned tasks during emergencies.
|
Plan of Correction
Two (2) Floor Monitors will be appointed on each floor of the CYWA. They will be trained and assigned emergency tasks during all emergencies. Floor monitors will be posted on each floor. Timeframe for accomplishment will be November 13, 2007.
All CYWA Staff/Samara House were trained in Fire safety, Evacuation and Fire Extinguisher Use on 11/13/07 by Craig Weaver of the Coatesville Fire Department.
Within seven (7) days of hire, new employees will be trained by Maria Lemus, LPN on Fire Safety, Evacuation and Fire Extinguisher Use.
D&A Program Director and CYWA Director of Housing Development will oversee Fire Safety Regulations to ensure compliance. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
|
Observations
Based on a review of the project's policies and procedures manual on October 3, 2007 it was determined that the project failed to have a written policy regarding the storage of all medications including controlled substances. Based on a review of the project's policies and procedures manual on October 3, 2007 it was determined that the project failed to have written policies and procedures regarding controlled substances. The project failed to identify where and how controlled substances were stored.
A physical plant inspection, which included the medication storage area, conducted on October 4, 2007 and again on October 5, 2007 revealed that clients receiving methadone medication "take home" bottles from an approved Narcotic Treatment Program were securing their take home bottles in a transportable locked box and giving it to facility staff to lock in a file cabinet. The clients had two keys for the lock box, the client kept one and the second key was given to a facility staff member. The key given to facility staff was taped to the top of the lock box enabling any staff person to access this controlled substance. A discussion with the facility's LPN on October 5, 2007 revealed that the facility was unaware of proper procedures for securing controlled substances, specifically methadone.
|
Plan of Correction
Upon arrival each resident will meet with the Nurse (LPN) or Samara House staff. The resident will be taken to where the lock box will be locked and stored. The resident will maintain possession of one (1) lock box key; the 2nd key will be given to CRC by the resident. Samara House staff will open the locked cabinet and the lock box will be placed inside and the cabinet will be relocked. The resident will be given the lock box to take with her at CRC Methadone distribution time. Upon arrival Methadone to be checked in by Samara House staff and the client. Documentation will be done on the Narcotics Sheet. Once verification is completed, the lock box is to be locked in the locked medicine cabinet. Client will maintain a key. The lock box will not be removed from the locked cabinet except at the scheduled dosing time and in the presence of the resident.
At 9 a.m. meds administration time, the resident will come to the designated area with the key to unlock the box and take her scheduled dose. At no time, can the client leave the designated area with the Methadone. The client and Samara House staff will sign the meds out. Empty bottles will remain in the lock box and not leave the designated area. Missed doses will be reported and returned to CRC by Samara House staff. Documentation will follow. At no time, may the client double up doses.
LPN trained all staff as to Medication Control on 11/7/07. Person responsible for ensuring compliance of Medication Control is the LPN. Timeframe for compliance is 11/7/07. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
|
Observations
Based on a review of two client records it was determined that the facility failed to provide an individualized treatment and rehabilitation plan with short and long-term goals formulated by both staff and client. A review of client records #1 and 2 conducted on October 4, 2007 revealed that the individualized treatment and rehabilitation plans had the same short and long-term goals. There was no individualization in formulating the treatment and rehabilitation plan.
|
Plan of Correction
Clinical staff was trained by the CYWA Director of D&A & Prevention Services on the State Regulation 709.92 as it related to short and long term goals relating individually to all clients on October 15, 2007, effective the same date. Client files will be reviewed by the Director 2X's monthly to ensure individualized treatment planning and compliance.
|