INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 8, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Daystar Center for Spiritual Recovery 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of seven personnel records, the project failed to ensure that one employee received at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
Employee #7 was hired as a Recovery Specialist on October 15, 2022, and was to have the communicable disease training by October 15, 2024; however, there was no documentation in the personnel file of the completion of a Department approved TB/STD training as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
To address citation 704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
For employee #7 there was no documentation in the personnel file of the completion of a department approved TB/STD training as of the date of the inspection.
The following has been Implemented to resolve this citation:
Due to the inability to find training, compliance with 704.11 Employee 7 does have a training for TB/STD already scheduled for 2/28/25.
This correction will be completed on 2/28/25. The COO will oversee the implementation of this plan of correction.
The CEO will ensure overall compliance
|
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on the review of client records, the project failed to document a complete client record on an individual that included verification that work done by the client at the project was an integral part of the treatment and rehabilitation plan in seven of seven client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
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: (12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
Daystar was able to fix this issue on 1/13/2025. Life skills that include daily chores were placed into all treatment plans as part of 3.1 level of care.
The program director will continue to monitor the inclusion of chores on all treatment plans through chart reviews. The executive director ensures overall compliance
The following has been Implemented on 1/13/2025, to resolve this citation:
The chores that clients are assigned as part of the 3.1 level of care will be attached to a goal of life skills on the individual treatment plan.
This correction was implemented on 1/13/25.
The COO will be responsible for The compliance
The CEO will ensure overall compliance.
|