INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 26, 2023 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:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on one applicable employee personnel records reviewed, the facility failed to provide documentation of six months supervision to include one hour of direct observation for a counselor assistant with a bachelor ' s degree for employee # 5. Employee # 5 was hired as a counselor assistant on August 22, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 5's personal record there was no documentation of six months supervision that included one hour of direct observation with a bachelor's degree. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address citation 704.9 (c), the following Has been implemented.
Employee #5 did not have proper documentation to prove 1 hour of direct observation. Daystar will continue supervision with employee #5 until this requirement is completed on July 1,2023
When a counselor assistant is employed at Daystar Center for Recovery, the Clinical Supervisor will ensure that documentation for direct observed supervision will be correctly documents and states direct observed supervision is conducted weekly for the first year of employment for high school level counselor assistants, and for the first 6 months of employment for bachelor level counselor assistants.
This correction was implemented on 2/1/2023. The Program Director will oversee the implementation of this plan of correction.
The CEO will ensure overall compliance
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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 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. A microwave oven on the 2nd floor had a broken handle on the door.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.2 (2) Building Exterior and Grounds, the following will be implemented:
Beginning 2/1/2023. The House Manager Supervisor will conduct a weekly inspection of the facility plant to ensure that all appliances and furniture are not broken and working properly.
The microwave was not being used so the solution was to throw it away om 2/1/2023.
The Program Director will monitor this procedure to ensure that the Daystar Center for Recovery is adhering to this standard.
CEO will ensure overall compliance. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. A fire exit door was unable to be opened easily and needed to be forced opened.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address citation 705.10 (a) (1) (i) Fire Safety, the following will be implemented:
On 2/1/2023 the fire exit window was greased and oiled. The exit now opens easily.
Beginning 2/1/2023. The Facility Maintenance Person will conduct weekly inspection of fire exit doors to ensure that they are easily accessible and able to open.
The Program Director will monitor this procedure to ensure that the Daystar Center for Recovery is adhering to this standard.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on one of one applicable client records reviewed, the facility failed to notify the clients emergency contact after the client left against facility advice per the facility policy and procedure manual.Client #7 was admitted on August 15, 2022 and was discharged on October 16, 2022. There was no documentation of the emergency contact being notified upon the client ' s discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address citation:
Client #7 staff failed to contact emergency contact and document. Upon further investigation a family member was contacted on the next and staff did not document.
The Clinical Supervisor did conduct a training course with all staff by 2/11/23. The Clinical Supervisor will review the procedure for contacting emergency contact when a client is discharged from the facility under any circumstance. He will also review written procedure and ensure that clinicians are following up with families if discharge occurs on the weekend.
Completion of these documents will be monitored by the Clinical Supervisor via Monday staff meetings.
Quality Improvement.
Discussions regarding compliance and/or non-compliance will continue in supervision with the clinicians as well as performance evaluations as needed.
Person responsible: Clinicians/Clinical Supervisor
Person responsible for monitoring: Clinical Supervisor/ Program Director
CEO will ensure overall compliance.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on one of five employee personal records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations reviewed and signed by the employee. Employee # 1 was hired as the Project director on February 10, 2015 and was still in this position at the time of the inspection. An annual performance evaluation was completed June 25, 2021. The next annual performance evaluation was due no later than June 25, 2022. There was no documentation of annual performance evaluation provided by the facility in 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.26 (b) (3) LICENSURE
Personnel management.:
to ensure compliance to the Board requirement to complete an annual evaluation the CEO will remind the Board annually at the yearly Board banquet in April.
The Board was notified of the citation
and they will complete the evaluation on 3/30/2023.
The Board President is responsible for completion of CEO annual evaluation.
CEO will ensure overall compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on six of seven client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services. Client # 1 was admitted on October 18, 2022 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on October 31, 2022 however, there was no documentation of frequency of services.Client # 2 was admitted on October 31, 2022 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on October 31, 2022 however, there was no documentation of frequency of services.Client # 3 was admitted on November 2, 2022 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on November 2, 2022 however, there was no documentation of frequency of services.Client # 4 was admitted on November 16, 2022 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on November 16, 2022 however, there was no documentation of frequency of services.Client # 5 was admitted on April 21, 2022 and was discharged May 24, 2022. A comprehensive treatment and rehabilitation plan was developed with the client on April 28, 2022 however, there was no documentation of frequency of services.Client # 7 was admitted on August 15, 2022 and was discharged October 16, 2022. A comprehensive treatment and rehabilitation plan was developed with the client on August 23, 2022 however, there was no documentation of frequency of services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.52 (a) (2) LINCENSURE TX Type & Frequency:
Records pulled Client 1,2,3,4,5,6, and 7.
Beginning 2/1/2023. The correction was made to the individual treatment by our electronic records company to make it visible on each plan to include frequency and service provided to the client.
Clinical Supervisor will oversee compliance of this policy with weekly chart audits.
Program Director will review monthly with Clinical Supervisor to ensure this policy is implemented.
CEO will ensure overall 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 three of three applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 7 days, 30 days, and 60 days after discharge and then 1 year after discharge.Client # 5 was admitted on April 21, 2022 and was discharged on May 24, 2022. Follow-up information was due no later than May 31, 2022, June 24, 2022, and July 24, 2022 however, there was no documentation of follow-ups for these dates in the client record.Client # 6 was admitted on May 9, 2022 and was discharged on October 7, 2022. Follow-up information was due no later than October 14, 2022 and November 14, 2022 however, the follow-up did not occur until November 18, 2022. A 60-day follow-up was due no later than December 14, 2022 however, there was no documentation of a follow-up for this date in the client record. Client # 7 was admitted on August 15, 2022 and was discharged on October 16, 2022. Follow-up information was due no later than October 23, 2022 and November 16, 2022 however, the follow-up did not occur until December 28, 2022. A 60-day follow-up was due no later than January 16, 2023 however, there was no documentation of a follow-up for this date in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.53 (a) (11), the following will be implemented:
There were 3 clients with incomplete follow-ups. client 5,6, and 7
Beginning on 2/1/2023, the Case Manager will ensure that all follow-up contacts are completed on all clients post discharge during the following intervals, 7 days, 30 days, 60 days, 90 days & 1 year.
We have improved our Eletronic records to send reminders to the case manager.
Clinical Supervisor will oversee compliance of this policy with weekly chart audits.
Program Director will review monthly with Clinical Supervisor to ensure this policy is implemented.
CEO will ensure overall compliance.
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