INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 6, 2009 licensure renewal inspection. The follow-up inspection was conducted on September 4, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Samara House of the 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 October 25, 2009.
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Plan of Correction
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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 a review of the facility's fire drill record during an unannounced follow-up inspection conducted on September 4, 2009, the facility failed to document alternate exit routes used during fire drills.
The findings include:
An unannounced follow-up inspection was conducted on September 4, 2009. Fire drill records showed documentation that the primary exit was used every month from May 2009 through August 2009. The secondary exit was only used in the month of April 2009.
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Plan of Correction
705.10 - Facility failed to document alternate exit routes during fire drills.
Notice was given to the Housing & Maintenance Director to begin immediately (10/12/09) to document and use alternate routes every other documented fire drill.
Person responsible: Housing Director
Director will oversee and check to make sure of compliancy.
Begin Date: 10/12/09 |
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 published in the local newspaper March 4, 2009, the facility failed to make available to the public an annual report for 2007/2008 fiscal year by the end of the fiscal year.
The findings include:
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.
This citation is being carried over as a result of the unannounced follow-up inspection conducted on September 4, 2009 because the time frame has not yet passed for the facility to come into compliance. The previously approved plan of correction for this citation will be carried over.
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Plan of Correction
709.22(e) - Facility failed to make public the Annual Report and Audit 7 months beyond end of physical year.
The Annual Report and Audit will be made available and advertised by December 31, 2009.
Person responsible: Executive Director |
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 during an unannounced follow-up inspection conducted on September 4, 2009, the facility failed to document complete psychosocial evaluations in three of four client records.
The findings include:
An unannounced follow-up inspection was conducted on September 4, 2009. Eight client records were reviewed. Psychosocial evaluations were required in four client records. The psychosocial evaluation listed client reported information and a repeat of the client's history gathered in the biopsychosocial assessment rather than a clinical assessment of the client in client records #1, 2 and 3.
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Plan of Correction
709.91 Intake and Admission - Intake shall include complete clinical assessments in biopsychosocials.
Counselors were trained on 10/12/09 on how to complete assessments in biopsychosocial assessments. They were also given a copy of the State Regulations.
Person responsible: Director to check all biopsychosocials within 5 days of admission to ensure compliance.
Begin date: 10/12/09
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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 a review of client records during an unannounced follow-up inspection conducted on September 4, 2009, the facility failed to document aftercare plans in four of four client records.
The findings include:
An unannounced follow-up inspection was conducted on September 4, 2009. Eight client records were reviewed. Four client records were required to have aftercare plans. The aftercare plans in client records #5 and 6 did not include goals with time frames. There were no timeframes documented for the aftercare goals in client records #5 and 6. The aftercare plans in client records #7 and 8 did not include any aftercare goals.
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Plan of Correction
709.93(a)(9) - Complete client record After Care Plan.
The facility failed to document After Care goals with timeframes and 2 files did not have completed goals.
Director trained Counselors on 10/12/09 as to the completion of After Care Plans. After Care Plans were changed and columns added for goals with timeframes. Counselors were given a copy of the State Regulations on 10/12/09.
Person repsonsible: Director will check all After Care Plans before d/c to ensure compliance.
Begin date: 10/12/09
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