INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SpiritLife, Inc. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of at least one year of experience with a bachelor's degree for employee # 4.Employee # 4 was hired as a counselor assistant on July 1, 2021 and promoted to a counselor on October 11, 2021. Employee # 4 did not have at least one year experience prior to the promotion.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director created a hiring policy and procedure for the facility that outlines the regulations for hiring counselors. This policy now clearly states that in order to be eligible for a counselor position, documentation of at least one year of experience with a bachelor's degree in a qualifying field of study must be present. Clinical Director will review all new potential hires qualifications prior to official offers being made. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #12 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #12 was hired as a kitchen assistant on August 19, 2019 and was due to have the communicable disease trainings no later than August 19, 2021. HIV/Aids training was not completed until January 27, 2022 and TB/STD training was not completed until February 15, 2022.The findings were discussed with facility staff during the licensing process.This is a repeat citation from the March 10, 2021 and the March 12, 2020 annual licensing inspection.
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Plan of Correction
The Compliance Officer has reviewed all personnel files to ensure all staff hired have received their HIV/AIDS and TB/STD within the regulatory timeframe. Compliance officer will schedule HIV/AIDS and STD/TB trainings quarterly and monitor on going compliance with training requirements for each department. Clinical Director will complete a secondary audit of trainings twice a year to ensure compliance. |
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 a review of a review of personnel records and staff schedules, the facility failed to ensure CPR certification and first aid training being 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. January 15 and January 16, 2022 from 7 am to 7 pm did not have staff with active CPR and first aid training certification.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff received CPR trainings on 1/14/22 and 2/7/22 that brought all CPR card holders on the shifts back into date to ensure coverage across all shift and departments. Compliance officer will monitor schedules and CPR certifications to ensure no further lapses in CPR/First Aid Coverage occur. |
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 a 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 outside dumpster lids were not closed and several trash containers in the kitchen area were not covered with lids.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance Supervisor and Compliance officer will complete walk throughs for the facility multiple times daily to ensure all trash receptacles and dumpster lids are closed. Signage was also posted on the dumpster reminding all staff to close the dumpster lids after use. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, a bathroom located in room 203 had an exhaust fan that was inoperable.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Room 203 exhaust fan was repaired on 3/8/22. Maintenace Supervisor and Compliance Officer will be responsible for weekly walkthrough of the facility to test all exhaust fans to ensure all are in proper operating condition. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The shower in room 310 was not able to be turned on from the faucet.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The shower in room 310 was repaired on 3/4/22. The Maintenace Supervisor and Housekeeping were provided a new checklist that checks all faucets are properly functioning on a daily basis and informing Maintenace of any necessary repairs immediately. The Compliance Officer will be responsible for collecting these checklists on a weekly basis. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor. Food items were stored on the floor throughout the kitchen area.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Chef ordered all new shelving units with bottom shelves to keep all boxes of food raised off of the floor. Compliance officer will complete weekly walkthrough of kitchen to ensure ongoing compliance. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection, the facility failed to keep interior exits and stairs lighted at all times. The second-floor stairway lighting fixtures were not operable and unable to provide light.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The second-floor stairwell light was fixed on 3/4/22. Housekeeping will be responsible for testing the stairwell lights 3 times daily to ensure the lights are all in working condition. The Compliance Officer will also do weekly checks to ensure all stairwell lights remain in working condition. |
705.10 (c) (2) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(ii) The extinguisher shall be located near an exit and away from the cooking area.
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Observations
Based on a physical plant inspection, the facility failed to store a fire extinguisher near an exit and away from the cooking area. A fire extinguisher was placed on a ledge next to the stove.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Extinguisher placement was evaluated by Cherryhill Fire Department and moved away from the cooking areas and placed nearer to the exit. Compliance officer will do quarterly checks to ensure on going compliance with new placement of fire extinguisher. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguishers throughout the entire facility expired in February 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Cherryhill Fire Department came through and inspected all fire extinguishers and signed off on inspection. Maintenance Supervisor and Compliance Officer will check all fire extinguisher on a quarterly basis and collaborate accordingly with Cherryhill Fire Department to ensure on going compliance with fire extinguisher inspections. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documentation, the facility failed to document an annual financial audit for the year ending June 30, 2021.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 10, 2021 annual licensing inspection.
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Plan of Correction
SpiritLife is in the process of having the audit for year ending June 30, 2021 completed by May 15th, 2022. The Controller will then ensure that all audits will be completed by year end moving forward. |
709.28 (c) 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.
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Observations
Based on one of twelve client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 3. Client # 3 was admitted on February 24, 2022 and was still active at the time of the inspection. A letter allowing admission information dated March 1, 2022 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff were re-trained on 3/10/22 on the appropriate way to address letters to third party entities utilizing the exact name or organization that is listed on the release of information. Compliance officer and Clinical Supervisor will conduct monthly chart audits to ensure compliance with all confidentiality expectations. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on one of twelve client records reviewed, the facility failed to document a completed informed and voluntary consent from the client for the disclosure of information to include the dated signature of the witness.Client # 9 was admitted on February 16, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 18, 2022 to a family member did not include the dated signature of the witness.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The individual responsible for filling out the release on client #9 was retrained on 3/8/2022 on how to complete informed and voluntary consents in its entirety. The Compliance Officer and Nursing Supervisor will be responsible for completing weekly chart audits and ensuring that all consents are filled out properly and completely. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on twelve of twelve client records reviewed, the facility failed to document written acknowledgement by clients they have been notified of their rights to include the project cannot discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Based on a review of client records, color and sex were missing from the client ' s acknowledgement of their rights. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation noting a client's right to not be discriminated against in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion was updated to include color and sex. Compliance Officer will be responsible for ensuring any current and future paperwork that includes client rights includes the rights in its entirety. |
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 one of one applicable client record reviewed, the facility failed to document, in writing, of a decision to involuntarily terminate the client ' s treatment and the reason for termination at the project. Client # 11 was admitted on December 8, 2021 and was administratively discharged on December 20, 2021. There was no documentation of termination in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff were retrained on 3/10/22 about the importance of filling out an involuntary discharge form when a client is being behaviorally discharged to ensure the client is notified of a decision to involuntarily terminate the client ' s treatment and the reason for termination. Clinical Supervisor will oversee all involuntary discharges moving forward to ensure counselors and RAs are following proper procedures and documenting appropriately on Involuntary Discharge form. |
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 five of six applicable client records reviewed, the facility failed to provide counseling services according to the individual treatment and rehabilitation plan in client records # 7, 8, 9, 10, and 12.Client # 7 was admitted on February 9, 2022 and was still active at the time of the inspection. An individual treatment and rehabilitation plan dated February 10, 2022 and updated February 17, 2022 indicated one individual session weekly. A review of progress notes and the client record service indicate the last individual session occurred on February 17, 2022.Client # 8 was admitted on February 5, 2022 and was still active at the time of the inspection. An individual treatment and rehabilitation plan dated February 5, 2022 and updated February 14, 2022 indicated one individual session weekly. A review of progress notes and the client record service indicate the last individual session to have occurred on February 16, 2022.Client # 9 was admitted on February 16, 2022 and was still active at the time of the inspection. An individual treatment and rehabilitation plan dated February 18, 2022 indicated one individual session weekly. A review of progress notes and the client record service indicate the last individual session to have occurred on February 18, 2022.Client # 10 was admitted on February 3, 2022 and was still active at the time of the inspection. An individual treatment and rehabilitation plan dated February 7, 2022 indicated one individual session weekly. A review of progress notes and the client record service indicate the last individual session to have occurred on February 7, 2022.Client # 12 was admitted on October 13, 2021 and was discharged on November 10, 2021. An individual treatment and rehabilitation plan dated October 13, 2021 indicated one individual session weekly. A review of progress notes and the client record service indicate the last individual session to have occurred on October 22, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff was retrained on the completion of treatment plans and treatment plan updates and noting accurate number of services provided for the client on a weekly basis. Clinical Staff were also re-trained on the expectation of keeping the charts up to date to reflect the services being provided on a daily basis. Clinical Supervisor will be responsible for on-going chart audits to ensure compliance with treatment plan documentation and charting in a timely manner. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on three of six applicable client records reviewed, the facility failed to provide a complete client record to include a record of service in client records # 7, 8, and 9. The record of service provided in the client records did not include documentation of individual sessions.Client # 7 was admitted on February 9, 2022 and was still active at the time of the inspection. Progress notes indicated an individual session occurred on February 17, 2022 but was not documented on the client record of service.Client # 8 was admitted on February 5, 2022 and was still active at the time of the inspection. Progress notes indicated an individual session occurred on February 16, 2022 but was not documented on the client record of service.Client # 9 was admitted on February 16, 2022 and was still active at the time of the inspection. Progress notes indicated an individual session occurred on February 18, 2022 but was not documented on the client record of service.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff were re-trained on 3-10-2022 on the importance of filling out and filing their record of service and clinical notes in a timely manner to accurately reflect the services that are being provided on a daily basis. Clinicians responsible for chart 7,8,9 (if still employed) were re-trained on accurately filling out the Record of Service. Clinical Supervisor will be responsible for completing weekly chart audits to ensure on going compliance. |