INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 14 through February 15, 2012, licensure renewal inspection. The follow-up inspection was conducted on July 25, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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(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 personnel records were for counselors and were required to include documentation of 25 hours of annual training. The facility's training year 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 of training for the 2011 training year. The facility provided documentation that employee # 2 attended 21 hours of training.
This was still out of compliance at the time of the follow-up conducted on July 25, 2012.
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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. |
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 one of three client records.
The findings include:
Four client records were reviewed on July 25, 2012; three records were reviewed for documentation of consents to release information. The consent to release information in record # 4 did not indicate what specific information was to be released to the party to whom the disclosure was being made.
Client # 4 was admitted on April 5, 2012. A release of information form was signed on June 18, 2012, for a legal entity. The facility failed to document what information was to be released on the consent form.
These findings were discussed with the facility director and were not disputed.
This is a repeat citation from the February 14 through February 15, 2012 on-site licensing renewal inspection.
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Plan of Correction
Staff were again in-serviced on 8/23/2012 on the need to have consents correctly completed. Each client chart for new admissions will be reviewed by the Executive Director or the Compliance officer within 48 hours of the admission to ensure compliance. |
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 two of three client records.
The findings include:
Four client records were reviewed on July 25, 2012; three records were reviewed for contents for release of information. The consents to release information in records # 1 and 4 did not indicate the purpose of the disclosure.
Client # 1 was admitted on July 5, 2012 and discharged on July 9, 2012. A release of information form was signed on July 5, 2012, for a physician. The facility had checked "other" and failed to identify a specific purpose for the disclosure on the consent form. Additionally, releases of information for a pharmacy and another entity were signed on July 5, 2012 that failed to specify the purpose for the disclosure on the consent form.
Client # 4 was admitted on April 5, 2012. Release of information forms were signed on April 5, 2012, for a physician, another treatment program, pharmacy, and insurance company. A release of information form was signed on June 18, 2012, for a legal entity. The facility failed to specify the purpose for the disclosure on the consent forms.
These findings were discussed with the facility director and were not disputed.
This is a repeat citation from the February 14 through February 15, 2012, on-site licensing renewal inspection.
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Plan of Correction
Staff were again in-serviced on 8/23/2012 on the need to have consents correctly completed. Each client chart for new admissions will be reviewed by the Executive Director or the Compliance officer within 48 hours of the admission to ensure compliance. |
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 one of three client records.
The findings include:
Four client records were reviewed on July 25, 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 client record # 2.
These findings were discussed with the facility director and were not disputed.
This is a repeat citation from the February 14 through February 15, 2012, on-site licensing renewal inspection.
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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. All new client charts will be reviewed within 48 hours of admission by the Executive Director or the Compliance officer to insure compliance. Any remaining copies of the old form that does not include reasons the client entered treatment will be found and destroyed by 8/31/2012 |
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 three of three client records.
The findings include:
Four client records were reviewed on July 25, 2012. Three of the client records reviewed were discharged clients and were required to include documentation of a follow up attempt. The facility did not document a follow up in client records #1, 2 and 3. The facility policy stated that follow up will be attempted within seven days of departure.
Client # 1 was admitted on July 5, 2012, and discharged on July 9, 2012. A follow up attempt was due on July 16, 2012. The facility failed to document a follow-up attempt in this client record as of the date of the inspection.
Client # 2 was admitted on March 13, 2012, and discharged on July 5, 2012. A follow up attempt was due on July 12, 2012. 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 June 6, 2012, and discharged on June 25, 2012. A follow up attempt was due on July 2, 2012. The facility failed to document a follow-up attempt in this client record as of the date of the inspection.
These findings were discussed with the facility director and were not disputed.
This is a repeat citation from the February 14 through February 15, 2012, on-site licensing renewal inspection.
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Plan of Correction
Follow up calls will be the responsibility of the creative writing group leader, and will be made on tuesdays after group. Staff were in-serviced again on follow up policy at the 8/23/2012 staff mtg. Compliance with follow up attempts will be checked via a note from the creative writing group leader detailing which attempts were made each tuesday and visual inspection of the follow-up book each weds by the Executive Director or the Compliance Officer. Facility is in full compliance |