INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14 through February 15, 2012, by staff from the Division of Drug and Alcohol 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:
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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
Based on a review of the facility's staff schedule from January 22, 2012 through February 18, 2012, the facility failed to provide a sufficient number of staff persons trained in Cardio Pulmonary Resuscitation (CPR) during the project's hours of operation.The findings include: On February 14, 2012, copies of staff CPR and First Aid cards and the January and February work schedule provided by the facility were reviewed.Based on the work schedule and the CPR and First Aid cards provided by the facility, the facility failed to provide CPR coverage from 12 a.m. until 8 a.m. on January 23, 2012, January 30, 2012, February 6, 2012, and February 13, 2012. This finding was confirmed by the facility director. The employee who did not have current CPR coverage was immediately told not to report to work for any scheduled shift.
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Plan of Correction
A tab has been added to the staff training section of our operations manual containing copies of all employee's CPR cards. This tab will be checked once a month by the administrative assistant to insure compliance. Facility is in full compliance |
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 documentation reviewed in the agency training records, the facility failed to ensure that one of two counselors received the required 25 hours of training annually.The findings include:Six personnel records were reviewed on February 14, 2012. Two of those records were counselors requiring 25 hours of annual training. The facility's training year reviewed was January 1, 2011 through December 31, 2011. The review of the training record for employee # 2 revealed that they failed to obtain the required 25 hours training for the 2011 training year. The facility provided documentation that employee # 2 attended 21 hours of training.
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Plan of Correction
Training hours for counselors will be reviewed quarterly by the executive director and administrative assistant and memos will be issued to counseling staff in order to insure adequate annual hours. |
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
Based on a physical plant inspection, the facility failed to keep the facility in good repair at all times for the safety and well-being of residents, employees, and visitors.The findings include:The physical plant inspection was conducted on February 14, 2012. At approximately 3:30 p.m., the carpet on the steps leading from the first floor to second floor was observed to be torn. This presented a potential tripping hazard for employees and residents. Additionally, at the top of the stairs there was a hole in the wall that was covered with tape. The lounge on the third floor had a window with rotten wood and exposed nail points coming through the wood. This is an unsafe condition for clients and staff alike. Beneath the window there was also a hole in the wall that was in need of repair. Client bedroom # 2 on the second floor was observed to have water damage on the ceiling as evidenced by bubbling and cracking plaster as well as chipping paint. The kitchen floor was in the process of being repaired during the inspection. The floor was uneven and had exposed subfloor. The facility failed to keep the grounds of the facility safe and in good repair at all times for the safety and well-being of residents and employees. The areas of concern were discussed with the project director and were not disputed. .
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Plan of Correction
Operations manager is responsible for insuring that corrective actions are implemented. Recurrance of the deficiency will be prevented and compliance monitored by bi-weekly walk-throughs of the facility by operations manager who will report issues to the executive director, who will authorize work to be done by operations manger or contractors.
Carpet has been tacked down. Holes in wall will be repaired by April 6, 2012.
3rd floor lounge windowsill and hole beneath window will be repaired by April 6, 2012; nails have been pounded down and rendered harmless until repairs are completed.
Client bedroom #2 damage was due to an old leak that had previously been repaired. Damage to ceiling will be repaired by April 6, 2012.
Kitchen floor repairs are progressing and will be complete by March 14, 2012. |
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
Based on a review of the fire drill logs, the facility failed to document the completion of monthly unannounced fire drills.The findings include:A review of the fire drill logs was conducted on February 14, 2012. The fire drill log was reviewed from January 2011 through January of 2012. Documentation was missing for a fire drill conducted for the month of January 2012.This was discussed with the facility director and operations manager. The facility had tested the tamper valve in January of 2012. They did not have a fire drill and they did not evacuate the facility.
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Plan of Correction
All fire drills will include setting off the audible alarm and evacuation of the building. Operations manager will oversee ongoing compliance. Facility is in full compliance |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of administrative documentation, the project failed to develop goals and objectives that included time frames and available resources for the January 1, 2012 through December 31, 2012 fiscal year.The findings include:Administrative documentation was reviewed on February 14, 2012. The document that included the 2012 annual goals and objectives was reviewed. The annual goals and objectives for 2012 failed to include time frames and available resources. This was discussed with the project director and was not disputed.
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Plan of Correction
2012 annual goals and objectives will be reformatted to include time frames and available resources. This will be completed by March 7, 2012 and ongoing compliance will be the responsibility of the Executive Director |
709.28(c)(2) 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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of the client records, the facility failed to document consents to release information which identified the specific information to be disclosed in three of six client records. The findings include:Six client records were reviewed on February 15, 2012; all records were reviewed for documentation of consents to release information. The consents to release information in records # 1, 2 and 6 did not indicate what specific information was to be released to the party to whom the disclosure was being made. Client # 1 was admitted on October 4, 2011. A release of information form was signed on October 5, 2011 for a specific entity. The facility had checked "other" and failed to specify what information was to be released on the consent form. Additionally, a consent was signed for an insurance company and the facility failed to document what information was to be released on the consent form. Client # 2 was admitted on August 25, 2011. A release of information form was signed on October 20, 2011 for a case manager. The facility failed to specify what information was to be released on the consent form. Client # 6 was admitted on December 6, 2011. Release of information forms were signed on December 6, 2011 for a drug and alcohol treatment program, family member, insurance company, and probation officer. The facility failed to specify what information was to be released on the consent form. These findings were discussed with the facility director and were not disputed.
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Plan of Correction
Findings were discussed with employee #3, director and licensure specialist on 2/15/12. Staff were in-serviced on the issue during staff meeting on 2/16/2012. Facility is in full compliance. Ongoing compliance will be monitored by the executive director |
709.28(c)(3) 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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of the client records, the facility failed to document consents to release information which identified the purpose of the disclosure in three of six client records. The findings include:Six client records were reviewed on February 15, 2012: all were reviewed for content of releases of information. The consents to release information in records # 1, 2 and 6 did not indicate what the purpose of the disclosure. Client # 1 was admitted on October 4, 2011. A release of information form was signed on October 5, 2011 for an insurance company that failed to specify the purpose for the disclosure on the consent form.Client # 2 was admitted on August 25, 2011. A release of information form was signed on October 20, 2011 for a case manager that failed to specify the purpose for the disclosure on the consent form. Client # 6 was admitted on December 6, 2011. Release of information forms were signed on December 6, 2011 for a family member, insurance company, and probation officer. The facility failed to specify the purpose for the disclosure on the consent form. These findings were discussed with the facility director and were not disputed.
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Plan of Correction
Findings were discussed with employee #3, director and licensure specialist on 02/15/2012. Staff were in-serviced on the issue during staff meeting on 02/16/2012. Facility is in full compliance. Ongoing compliance will be monitored by the executive director |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of the facility's policy and procedures, client handbook, and client records, the project failed to document that the client was notified of their right to appeal a decision limiting access to his records to the project director and their right to request correction of inaccurate, irrelevant, outdated or incomplete information from his records, as required per regulation.The findings include:The policy and procedure manual was reviewed on February 14, 2012. Per regulation, the project is required to notify clients of their right to appeal a decision, limiting access to his/her records to the project director, and their right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records. Six client records were reviewed on February 15, 2012. The facility failed to notify clients # 1, 2, 3, 4, 5, and 6 of their right to appeal a decision limiting access to his records to the project director and their right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records. The project director was interviewed on February 14, 2012 and confirmed documentation provided to clients did not include those two required areas.
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Plan of Correction
Missing items in client rights were added to the resident handbook by the operations manager on 3/01/2012. All clients receive copies of the client handbook upon admission, which will prevent recurrance of the deficiency. In addition, recurrance wil be prevented by the addition of the full set of client rights to the appropriate section of the Operations Manual by the executive director, which will be completed on 3/09/2012 |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to ensure treatment and rehabilitation plans are reviewed and updated at least every 30 days in three of four records. The findings include:Six client records were reviewed on February 15, 2012. Four records were required to have an updated treatment and rehabilitation plan that included the client's progress on the stated goals of the previous treatment plan. The treatment and rehabilitation plans in records # 1 and 2 failed to show progress of the stated goals on the previous treatment and rehabilitation plan. Additionally, client record # 6 failed to include a treatment and rehabilitation plan. Client # 6 was admitted on December 6, 2011. The treatment and rehabilitation plan was documented on December 28, 2011. The treatment and rehabilitation plan update was due on January 28, 2011. The facility failed to document a treatment and rehabilitation plan update in this record as of the date of the inspection.
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Plan of Correction
Employees number 2 and 3 have been in-serviced on the necessity of documenting specific examples of progress on treatment pan revisions and updates and the necessity of completing updates on or before the date due. Facility is in full compliance. Ongoing compliance will be monitored by the executive director |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on review of client records, the facility failed to document a discharge summary that included the reason the client entered treatment in three of three client records.The findings include:Six client records were reviewed on February 15, 2012. A discharge summary was required in three client records. The facility did not document a discharge summary that included the reasons the client entered treatment in records # 1, 2, and 3.
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Plan of Correction
Final progress report has been modified by operations manager on 2/29/2012 to include reasons client entered treatment and diagnoses. Form has been renamed "Discharge Summary" to prevent confusion with other discharge forms and prevent recurrance of the deficiency. Staff were in-serviced on the new form on 3/01/2012. Facility is in full compliance |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on review of client records, the facility failed to document a follow up attempt in two of three client records.The findings include:Six client records were reviewed on February 15, 2012. Three of the client records reviewed were discharged clients and required a follow up attempt. The facility did not document a follow up in client records # 2 and 3. The facility policy stated that follow up will be attempted within seven days of departure.Client # 2 was admitted on August 25, 2011 and discharged on November 21, 2011. A follow up attempt was due on November 28, 2011. The facility failed to document a follow-up attempt in this client record as of the date of the inspection. Client # 3 was admitted on August 18, 2011 and discharged on September 12, 2011. A follow up attempt was due on September, 2011. The facility failed to document a follow-up attempt in this client record as of the date of the inspection.
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Plan of Correction
Facility will attempt to make follow up calls to clients numbers 2 & 3 on 3/8/2012.
Follow up calls will be the responsibility of the creative writing group leader, and will be made on fridays after group. Staff will be in-serviced on follow up policy at the 3/8/2012 staff mtg. Compliance with follow up attempts will be checked weekly by the executive director in order to monitor ongoing compliance.
Facility is in full compliance |