INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on March 5, 2019. Based on the findings of the on-site inspection, Daystar Center for Spiritual Recovery was found to not 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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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
During an onsite review of CPR and First Aid training of staff and staffing schedules on March 5, 2019, the facility failed to have a sufficient number of staff trained in First Aid to cover all scheduled shifts.
Eleven out of sixteen staff did not have a record of First Aid training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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.
(a) Daystar has developed a new system to track trainings. The new system will send a reminder to HR and staff. All Daystar staff that did not have first aid training were trained as a group on 3/15/2019. Currently the executive director is compliant on 2018/2019 trainings.
The Administrative Director will ensure compliance with training regulations and the Executive Director will ensure overall compliance.
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704.11(d)(1) LICENSURE Training Req-Proj/Fac Directors
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
During an onsite review on March 5, 2019, the facility failed to ensure that the project director and facility director had the required training hours.
The project director/facility director had 6 hours of training for the training year of July 1, 2017 through June 30, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director/facility director had 6 hours of training for the training year of July 1, 2017 through June 30, 2018.
These findings were reviewed with facility staff during the licensing process.
(a) Daystar has developed a new system to track trainings. The new system will send a reminder to HR and staff to help track individual training needs. We are unable to gain compliance for the training year 7/1/2017 - 6/30/2018 but currently the Executive Director is compliant on 7/1/2018/6/30/2019 trainings with 43 hours of trainings.
The Administrative Director will ensure compliance with training regulations and the Executive Director will ensure overall compliance. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
During a physical site inspection on March 5, 2019, the facility failed to maintain all structures on the grounds of the facility to be free from danger to health and safety.
The railing on the back deck was found to be loose.
The facility had various exposed wires in the basement area that was being used as a weight room for the residents.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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, and 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.
(a) The railing in the rear parking lot is loose. It is bolted into the cement. This repair will take place no later them 6/30/2019 when the weather is warmer and the cement sidewalk is repaired.
(b) The exposed telephone wires in the basement have been covered with a wooden box to eliminate any safety issues, this was completed on 3/11/2019.
Daystar Maintenance person will ensure compliance with training regulations and the Executive Director will ensure overall compliance.
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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
During a physical site inspection on March 5, 2019, the facility failed to keep the sidewalks around the building in good repair for the safety and well being of residents, employees and visitors.
The sidewalk had a large cracked piece missing on the left outside walkway. The sidewalk also had two large cracks alongside the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.2 (1) LICENSURE
Building exterior and grounds:
705.2. Building exterior and grounds. The residential facility shall: (1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
(a) The cement walkway to the right of the building is owned by the church next door. Daystar is willing to take responsibility for the repairs. A contractor has been hired to make the proper repairs when the weather is consistently warm enough.
Contractors info
Matt Kelly
Kelly Masonry
717-610-0200
PA License # 097045
Compliance will be no later than 6/30/2019.
Daystar Maintenance person will ensure compliance with training regulations and the Executive Director will ensure overall compliance.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
On March 5, 2019, during a review of monthly fire drills from January 4th through December 30th, 2018, the facility failed to have unannounced fire drills at least once a month.
The facility failed to conduct fire drills in the months of June 2018 and July 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.10 (d) (1) LICENSURE
Fire safety:
705.10. Fire safety. (d) Fire drills. The residential facility shall: (1) Conduct unannounced fire drills at least once a month.
(a) Daystar has implemented a new fire drill alert system with an electronic form to be filled out post fire drill. the new system will remind staff prior to the next 30 days so a drill can be completed. This program was implemented on 3/20/2019.
Daystar House Manager will ensure compliance with training regulations and the Executive Director will ensure overall compliance.
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705.10 (d) (2) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
On March 5, 2019, during a review of monthly fire drills from January 4th through December 30th, 2018, the facility failed to conduct fire drills during normal staffing conditions.
The fire drill conducted on January 4, 2018 was documented as having 5 staff working at 4 am, when normal staffing is 1 staff during the overnight hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.10 (d) (2) LICENSURE
Fire safety:
705.10. Fire safety. (d) Fire drills. The residential facility shall: (2) Conduct fire drills during normal staffing conditions.
(a) Daystar has implemented a new fire drill alert system with an electronic form to be filled out post fire drill. The electronic form has specific directions and all staff were trained on properly implementing the form. This program was implemented on 3/20/2019.
Daystar House Manager will ensure compliance with training regulations and the Executive Director will ensure overall compliance.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
On March 5, 2019, during a review of monthly fire drills from January 4th through December 30, 2018 the facility failed to indicate if any problems were encountered and whether the fire alarm or smoke detector was operative.
The facility failed to document if any problems were encountered and whether the fire alarm or smoke detector were operative on the fire drill record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
705.10 (d) (4) LICENSURE
Fire safety:
705.10. Fire safety. (d) Fire drills. The residential facility shall: (4) maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
(a) Daystar has implemented a new fire drill alert system with an electronic form to be filled out post fire drill. The electronic form has specific directions to include monthly drills. All staff were trained on properly implementing the form. This program was implemented on 3/20/2019.
Daystar House Manager will ensure compliance with training regulations and the Executive Director will ensure overall compliance.
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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
On March 5, 2019, during a review of monthly fire drills from January 4th through December 30, 2018, the facility failed to conduct a fire drill during sleeping hours at least every six months.
The facility had a sleeping fire drill on January 4, 2018 at 4 am and then not another sleeping fire drill until October 31, 2018 at 6 am.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
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.
(a) Daystar has implemented a new fire drill alert system with an electronic form to be filled out post fire drill. The new electronic alert system will notify staff when an overnight drill is required. This program was implemented on 3/20/2019.
Daystar House Manager will ensure compliance with training regulations and the Executive Director will ensure overall compliance.
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705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
On March 5, 2019, during a review of monthly fire drills from January 4th through December 30th, 2018, the facility failed to conduct fire drills on different days of the week.
Five out of eleven fire drills completed in 2018 were conducted on a Sunday.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.10 (d) (7) LICENSURE
Fire safety:
705.10. Fire safety. (d) Fire drills. The residential facility shall: (7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
(a) Daystar has implemented a new fire drill alert system with an electronic form to be filled out post fire drill. The new electronic alert system will pick random dates to conduct fire drills before 30 days of the last fire drill. This program was implemented on 3/20/2019.
Daystar House Manager will ensure compliance with training regulations and the Executive Director will ensure overall compliance.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on an onsite client record review on March 5, 2019, the facility failed to provide counseling services as stated in the treatment plan in four out of seven client records.
Client # 2 was admitted on January 10, 2019 and was still active at the time of the inspection. The client did not receive a weekly counseling session during the week of February 17th-23rd, 2019 as per the treatment plan dated February 13, 2019.
Client # 3 was admitted on January 16, 2019 and was still current at the time of the inspection. The client did not receive weekly counseling sessions for the weeks of February 10th-16th, 2019 and February 24th-March 2nd, 2019 as per the treatment plans dated January 23 and February 22, 2019.
Client # 5 was admitted on January 9, 2018 and was discharged April 5, 2018. The client did not receive weekly counseling for the weeks of February 4th-February 10th, 2018; February 11th-February 17th; 2018; February 18th-February 24th, 2018; March 4th-March 10th, 2018; and March 18th-March 24, 2018 per treatment plans dated January 9, 2018, January 16, 2018, February 15, 2018 and March 15, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.52(c) LICENSURE
Provision of Counseling Services:
709.52. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
(a) Daystar has developed new treatment plan forms for phase 2 and phase 3 to reflect bi weekly individual sessions to comply with state regulations. Monthly chart review forms will reflect this area of Compliance. Daystar achieved on 3/11/2019 in regard to this issue.
Daystar Program Director and Lead Counselor will ensure compliance with training regulations and the Executive Director will ensure overall compliance.
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