INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4, 2009 through March 6, 2009 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 April 2, 2009
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on the review of the facilities policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan for the training year 2007/2008.
Findings:
The policy and procedure manual was reviewed on March 4, 2009. The annual evaluation of the overall training plan addressed only one training rather than an assessment of the entire training year.
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Plan of Correction
The Director will include all trainings for the entire training year when completing the Assessment of Annual Training for 2008/09 and yearly thereafter.
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The Director and CQI/Nurse will check all trainings, based on training logs and address all trainings in the Assessment, so as to not occur again.
Person responsible for continued compliance -- Director and CQI/Nurse. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of CPR/First Aid listing of staff trained and the facility's four week schedule for the month of February 2, 2009 through March 1, 2009, the facility failed to provide sufficient coverage of staff persons who are CPR certified.
Findings
During the review of the facility's summary report and 4 week work schedule it was shown that the facility did not have sufficient CPR coverage for the week of February 2, 2009 through February 8, 2009; 2/2/09 6 AM to 1:21 PM and the evening shift 10:30 PM to 6 AM, 2/3/09 6 AM to 8:53 AM and the evening shift 9:47 PM to 7 AM, 2/4/09 7 AM to 8:37 AM then the evening shift 10:47 PM to 6 AM, 2/5/09 6 AM to 8:35 AM then the evening shift 10:30 PM to 7:30 AM, 2/6/09 7:30 AM 8:38 AM then the evening shift 9:20 PM to 7:54 AM, 2/7/09 9:25 PM to 10:40 AM. The staff that was appointed those days to work did not have their CPR certifications
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Plan of Correction
As of 3/8/09, all Samara House staff have been trained in CPR, except for one (1) part-time Aide who is not permitted to work in Samara House until her training certificate is produced. Director and CQI to ensure this regulation is in ongoing compliance. Copies of CPR cards have been placed in personnel files.
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All personnel files will be checked by CQI two (2) times yearly to ensure all personnel in Samara House have a valid CPR/First Aid Card. Dates will be set up for all staff in need of recertification before their card's expiration date. Any staff in non-compliance will be suspended until certification is completed. Director to ensure this process is happening so as to not repeat this non-compliance.
Person responsible for continued compliance -- Director. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's fire drill record on March 4, 2009, the facility failed to conduct a fire drill during sleeping hours for at least every 6 months.
Findings:
The last overnight fire drill was conducted on February 27, 2009 and the last one before this was conducted in November 2007.
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Plan of Correction
The Housing & Maintenance Director was given training and a copy of the Fire Safety Policy. Fire drills will be held overnight during sleeping hours at least every six (6) months and documented. Person repsonsible -- Housing & Maintenance Director.
Person responsible for continued compliance -- The Housing Director will ensure implementation of this corrective action. LPN/CQI Coordinator will monitor for compliance. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on of the facility's fire drill log on March 4, 2009, the facility failed to document alternate exit routes.
Findings:
The "primary" exit was used every month from April 21, 2008 through March 1, 2009. No other alternate exit was used or documented in the fire drill record.
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Plan of Correction
The Housing Director was given training on 3/17/09 on Fire Safety and received a copy of the regulation. Fire drills will need to document alternate routes, as well as primary. The Housing Director will train his staff to document and use the alternate routes intermittently. Person responsbile to ensure compliance is the Housing Director. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the facility's policy and procedure manual and the review of the notice in published statement the local newspaper on March 4, 2009, the facility failed to make available to the public an annual report for the 2007/2008 fiscal year by the end of the fiscal year.
Findings:
The annual report was not made available to the public until January 7, 2009, which was more than 7 months beyond the end of the fiscal year.
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Plan of Correction
The Executive Director will ensure our next Annual Report (08/09) ad will be placed in the newspaper, stating the Annual Report is available, by the end of the fiscal year, June 30, 2009. Executive Director will ensure compliance with this regulation. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in one of three client records.
Findings:
Eight client records were reviewed on March 5, 2009 through March 6, 2009. Psychosocial evaluations were required in one client record. The psychosocial evaluation had listed responses and client stated comments rather than a clinical assessment of the client that included problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, attitude toward treatment and the counselor's impression of the client in client record #1.
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Plan of Correction
The Director presented a training to all staff and clinical staff on 3/17/09 addressing Psychosocial Evaluations. Staff was informed of the need to address problems/needs, assets/strengths, support systems, coping mechanisms and/or negative factors that might inhibit treatment and the Counselor's impression.
Director and CQI will review each admission to ensure compliance with this regulation. |
709.93(a)(9) LICENSURE Client records
709.93. 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 aftercare plans in two of three client records.
Findings:
Eight client records were reviewed on March 5, 2009 through March 6, 2009. Aftercare plans were required in two client records. The facility failed to include the contact person and reentry process in the aftercare plan for records #2 and 3. Also, client record #2 did not have goals with time frames listed.
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Plan of Correction
The Director presented an in-house staff training on 3/17/09 as to the Aftercare Plans and its regulation. To include goals and timeframes, contact person and re-entry process. Persons responsible to ensure compliance -- Director and CQI Coordinator. |