INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on March 9-10, 2021 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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704.11(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 and training records, the facility failed to document that support staff completed HIV/AIDS and TB/STD training within the first two years of employment.Staff #11 was hired as a support staff on November 28, 2016. TB/STD and HIV/AIDS training was due to be completed by November 28, 2018. There was no documentation of TB/STD and HIV/AIDS training documented in staff #11's record.Staff #12 was hired as a support staff on March 1, 2014. TB/STD and HIV/AIDS training was due to be completed by March 1, 2016. There was no documentation of TB/STD and HIV/AIDS training documented in staff #12's record.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 12, 2020 licensing inspection.
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Plan of Correction
Staff #11 and #12 will receive TB/STD and AIDA/HIV training before May 14, 2021. Clinical supervisor will provide quarterly checks to ensure staff #11 and #12 will comply with training requirements. Clinical supervisor will provide education on maintaining necessary trainings. All newly hired staff will be educated on training requirements and RS Supervisor will be responsible for signing all new employees up for STD/TB/HEP and Basic HIV within their first year of employment. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel and training records, the facility failed to document at least 25 hours of annual training.Staff #4 was hired as a counselor on October 2, 2016. Counselor #4 completed 16 hours of training for the 2020 training year.Staff #5 was hired as a counselor on March 12, 2018. Counselor #5 completed 12 hours of training for the 2020 training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor met with Staff #4 and Staff #5 to emphasize the expectation of meeting yearly training requirements. Clinical Supervisor will evaluate counselor personnel files quarterly to ensure compliance with counselor training requirements and address disparities in individual supervision to ensure 25 hours of annual training are being met yearly. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to restrict the use of heaters that are not permanently mounted or installed.The physical plant inspection was conducted on March 10, 2021. At the time of the inspection, a portable heater was observed in the intake office.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A physical plant inspection will be done quarterly by maintenance supervisor to ensure adherence to the restriction of any heaters that are not permanently mounted or installed. Staff will also be educated on the restriction of space heaters and asked to remove any heating device that does not meet state regulations by 3/31/21. |
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
The facility failed to conduct fire drills at least once a month.The fire drill logs for the period of March 2020 - February 2021 were reviewed on March 20, 2021. There was no fire drill conducted in the month of December 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance Supervisor was educated on March 11, 2021 on requirements for unannounced, monthly fire drills. Unannounced fire drills will be conducted monthly per regulations. Maintenance Supervisor was educated that when fire drills are conducted and a client(s) is in quarantine, the client may remain in room, supervised by staff, during the drill. |
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 years ending June 30, 2019 and June 30, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The auditors will complete the financial audit ending June 30, 2019 no later than May 30, 2021. The auditors will then work to complete the financial audit for June 30, 2020 no later than October 31, 2021. |
709.62(c)(4) LICENSURE Consent to TX
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a buprenorphine consent to treatment prior to the first dose of buprenorphine in client record #1.Client #1 was admitted on August 9, 2020 and discharged on October 1, 2020. The client's first dose of buprenorphine was on August 11, 2020. The client did not sign the consent to receive buprenorphine treatment until August 14, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to the initiation of Buprenorphine, the nurse on duty is responsible for checking the client chart to ensure a buprenorphine consent is on file. If there is not a buprenorphine consent on file, the nurse will be responsible for meeting with the client and going over the consent prior to the dosing of buprenorphine. Nursing supervisor will do monthly chart audits to ensure compliance. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of client records, the facility failed to document that it provided each female client of the possible risks to her unborn child.Client #1 was admitted on August 9, 2020 and discharged on October 1, 2020. The client's first dose of buprenorphine was on August 11, 2020. The client was not provided with the information of buprenorphine risks until after the first dose, August 14, 2020.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 12, 2020 licensing inspection.
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Plan of Correction
Clinical Director went over client #1 chart with intake nurse and nursing supervisor and discussed the importance of educating pregnant females of risks to unborn child if they choose to detox or utilize buprenorphine prior to the client beginning buprenorphine. On staff nurse will check client chart to ensure a buprenorphine consent has been completed prior to the client receiving their first dose of buprenorphine. Nursing Supervisor will complete monthly chart reviews to ensure compliance. |