INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2011 through December 6, 2011, 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.
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Plan of Correction
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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, the facility failed to keep the facility in good repair at all times for the safety and well-being of residents, employees, and visitors.
The findings include:
The physical plant inspection was conducted on December 5, 2011. At approximately 10:05 a.m. the carpet on the steps leading from the first floor to the basement was observed to be torn. This presented a potential tripping hazard for employees, residents, and visitors.
The CQI/LPN observed and confirmed this finding.
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Plan of Correction
At the time of the licensing visit, maintenance repaired the torn carpet on the steps. The Director of Housing & Maintenance will have the building checked daily by his staff to ensure safety issues are not present, beginning 12/6/11.
Person responsible: Director of Housing & Maintenance |
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 observation during the physical plant inspection, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
During the physical plant inspection, two dumpsters were observed at approximately 10:10 a.m. There was excess garbage sitting in crib outside of the dumpster. The crib was filled with what appeared to be clothing items.
The CQI/LPN observed and confirmed this finding.
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Plan of Correction
This non-compliance was taken care of at the time of licensing. The Director of Housing & Maintenance will check dumpsters at 7:00 am daily to ensure closure and no excess garbage, beginning 12/6/11. Another dumpster will be ordered if the need arises.
Person responsible: Director of Housing & Maintenance |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to provide slip resistant surfaces in two of five of the bathtubs and showers.
The findings include:
A physical plant inspection was conducted on December 5, 2011. Five bathtubs/showers were required to have slip resistant flooring. The facility did not provide slip resistant flooring in the bathtub # 2 and 3.
The CQI/LPN observed and confirmed this finding.
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Plan of Correction
Missing strips in the showers were replaced at the time of the licensing visit on 12/6/11. CQI will check daily, along with Counselor's Aides to ensure strips are still in place, beginning 12/6/11.
Person responsible: CQI/Counselor's Aides |
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 an inspection of the physical plant, the facility failed to ensure that frozen food was being stored at or below 0F, as required by regulation.
The findings include:
The kitchen was inspected on December 5, 2011 at approximately 10:15 a.m.. Per regulation, a residential facility that operates an onsite food preparation area or a central food preparation area shall keep frozen food at or below 0F. The thermometer in the chest freezer when you enter the facility showed the temperature to be 10F. A temperature log was reviewed which documented freezer temperatures between 10F and 20F; which is above the required temperature of 0F.
The CQI/LPN was interviewed and confirmed this finding. It was determined after installing a new thermometer that the thermometer that was being used was not working properly. The freezer temperature was again observed on December 6, 2011 and it was 0F.
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Plan of Correction
At the time of inspection on 12/6/11, the thermometer was replaced in the freezer. Thermometers to be read daily by Counselor's Aides.
We weill keep two (2) thermometrs on hand to be able to immediately replace an inoperative thermometer.
On 12/8/11 training was given to all Counselor's Aides staff in "Reading Thermometers Properly."
If found that this procedure is not being done properly, further discipline action will follow as per policy and procedures.
Person responsible: Counselor's Aides; Counselor's Aides Supervisor will reassure compliance.
CQI and Director to follow-up. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document an aftercare plan that included goals with measurable time frames in two of four client records.
The findings include:
Ten client records were reviewed on December 6, 2011. Eight records were from the inpatient residential program and four client records required aftercare plans. The facility did not document an aftercare plan that included goals with measurable time frames in client record # 3 and 4.
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Plan of Correction
Staff to ensure documentation of Aftercare Plans including goals with measurable timeframes for client records, beginning 12/6/11. Clinical staff training will be held of 12/21/11 presented by the Director on 709.53(a)(9) Aftercare Plans & Measurable Timeframes. Director and CQI will check all files at client discharge to ensure compliance.
Person responsible: Clinical Staff; Director & CQI to ensure compliance |