INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2023 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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705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical site inspection, it was determined that the facility failed to maintain protective caps over each electrical outlet. There was no protective cap in the outlet in bathroom #1.This finding was reviewed with the facility staff during the licensing inspection process.
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Plan of Correction
On 4/14/23 the Maintenance Engineer replaced the outlet cover in bathroom #1 to a built in child safe outlet.
Effective 5/8/23, the Maintenance Engineer and the Lead Counselor Aide will perform a daily walk-thru of the facility using a Physical Plant checklist developed by the Program Assurance Liaison. This check list will guide the Maintenance Engineer and Lead Counselor Aide thru the daily site inspection to identify any needed repairs or replacement of any safety mechanisms to include outlet covers. It will be the responsibility of the Lead Counselor Aide to keep an updated log of the daily inspection and to create a work order for any needed repairs. The work orders will be submitted to the Project/Facility and Program Directors for approval. Approved work orders will be given to the Executive Assistant(EA) for scheduling. The Maintenance Engineer will receive the approved work order from the EA and perform the repair. The work order will be updated to complete. Completed work orders and daily Physical Plant Check Lists will be placed in the On-Site Inspection Log daily to be maintained by the Lead Counselor Aide and audited weekly by the Program Assurance Liaison to ensure compliancy. |
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, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed in two out of seven records reviewed.Client #1 was admitted on February 8, 2023 and was still active at the time of the inspection. A release of information form was signed and dated on February 10, 2023 to a school district did not include the specific information to be disclosed. " Other " as checked but not specified. Client #6 was admitted on November 28, 2022 and was discharged on January 9, 2023. A release of information form signed and dated January 4, 2023 to another facility did not include the specific information to be disclosed.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the April 26, 2022 licensing inspection.
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Plan of Correction
On 4/14/23 the Project/Facility Director met with client #1 to complete the deficient Informed and Voluntary Consent Form to specify the information to be disclosed.
Effective 5/8/23 a folder named "Consent to Release Information Audit Folder" will be introduced to the facility charting procedure. It will be the responsibility of the Project/Facility Director, Counselors, Case Managers, Lead Counselor Aide and Counselor Aides to place all new Consent to Release Information forms created for clients in the newly developed "Consent to Release Audit Folder". It will be the responsibility of the Night Audit Counselor Aide to inspect any Consent to Release Information Forms placed in the folder daily for completion and accuracy before placing in the clients chart. During the inspection if a Consent to Release Information Form is deficient it will be the responsibility of the Night Audit Counselor Aide to return the release to the writer for completion. It will then be the responsibility of the writer to correct the deficiencies and return to the "Consent to Release Information Audit Folder" for re-inspection and filing in the clients chart. Charts will be audited weekly for compliancy by the Program Assurance Liaison. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in two out of seven records reviewed.Client #5 was admitted on September 28, 2022 and was discharged on November 4, 2022. A release of information form was signed and dated on October 3, 2022 to a government agency and a form signed and dated on October 13, 2022 to a family member did not include the purpose of disclosure.Client #6 was admitted on November 28, 2022 and was discharged on January 9, 2023. Two release of information forms signed and dated January 4, 2023 to other facilities did not include the purpose of disclosure.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the April 26, 2022 licensing inspection.
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Plan of Correction
Effective 5/8/23 a folder named "Consent to Release Information Audit Folder" will be introduced to the facility charting procedure. It will be the responsibility of the Project/Facility Director, Counselors, Case Managers, Lead Counselor Aide and Counselor Aides to place all new Consent to Release Information forms created for clients in the newly developed "Consent to Release Audit Folder". It will be the responsibility of the Night Audit Counselor Aide to inspect any Consent to Release Information Forms placed in the folder daily for completion, accuracy and to ensure purpose of disclosure is indicated before placing in the clients chart. During the inspection if a Consent to Release Information Form is deficient it will be the responsibility of the Night Audit Counselor Aide to return the release to the writer for completion. It will then be the responsibility of the writer to correct the deficiencies and return to the "Consent to Release Information Audit Folder" for re-inspection and filing in the clients chart. Charts will be audited weekly for compliancy by the Program Assurance Liaison. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client records reviewed.Client #7 was admitted on October 14, 2022 and discharged on February 9, 2023. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 5/4/23 The Samara House Client Discharge Policy has been updated to now include that when a Clinical Decision is made to execute an Administrative Discharge, it will be the responsibility of the clients Counselor to submit in writing to the client the reason for the Administrative Discharge. The letter will further indicate that the client has the right to submit a Letter of Reconsideration. These policy updates have been reviewed with the Clinical Team(Counselor, Case Managers ,Lead Counselor Aide and Program Assurance Liaison) at the Weekly Case Consult Meeting held on 5/4/23. It will be the responsibility of the Counselor to place a copy of the Discharge Letter and any Reconsideration Letters in the "To Be Filed Folder" for the Night Audit Counselor Aide to place in the clients chart. It will be the responsibility of the Program Assurance Liaison to perform weekly chart audits to ensure that the documentation is present in the clients record. |
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
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of four discharged records reviewed. Per facility policy, follow up is to be completed at seven days, three months and six months.Client #4 was admitted on September 21, 2022 and was discharged on December 1, 2022. The seven day follow up call was due December 8, 2022 and was not completed until January 4, 2022. There was no three month follow up documented. Client #5 was admitted on September 28, 2022 and was discharged on November 4, 2022. There was no three month follow up documented. Client #6 was admitted on November 28, 2022 and was discharged on January 9, 2023. There was no three month follow up documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/8/23 The Program Assurance Liaison has developed an AfterCare Follow-Up Log. It will be the responsibility of the Lead Counselor Aide to add the client to the AfterCare Follow-Up Log when a client is removed from active status and placed in discharge status. The AfterCare Follow-Up Log will contain the clients name, date of discharge, reason for discharge, 7 Day Follow-up Date, 3 Month Follow-Up Date and 6 Month Follow-Up Date. It will be the responsibility of the Case Managers to review The AfterCare Follow-Up Log daily to determine if any follow-up contact to the former client is due for that day. If contact is due it will be the responsibility of the Case Manager to document the details of the call in the Samara House AfterCare Log. It will be the responsibility of the Program Assurance Liaison to audit the AfterCare Follow-Up Log weekly to ensure that all follow-up calls that are due have been made and documented in the Samara House AfterCare Log. |