INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1, 2022 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's fire drill log from January 29, 2021, to December 17, 2021, the facility failed to conduct a fire drill during sleeping hours at least every six months. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.10 (d) (5) LICENSURE
Fire safety.:705.10. Fire safety. (d) Fire drills. The residential facility shall: (5) Conduct a fire drill during sleeping hours at least every 6 months.
Observations:
Based on a review of the facility's fire drill log from January 29, 2021, to December 17, 2021, the facility failed to conduct a fire drill during sleeping hours at least every six months.
These findings were reviewed with facility staff during the licensing process.
705.10 (d) (5) LICENSURE
Fire safety.:705.10. Fire safety. (d) Fire drills. (5) Conduct a fire drill during sleeping hours at least every 6 months.
POC
As of, 2/2/2022, Daystar Center has implemented a new procedure to plan all fire drills in advance for the entire year. This procedure will ensure that all fire drills are completed at the appropriate times in accordance with DDAP regulations of 2 overnight drill every 6 months. The fire drill will be reviewed monthly by the program director and the executive director will ensure overall compliance.
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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.
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Observations
Based on a review of the client records, the facility failed to document on the client treatment and rehabilitation plan that the work completed at the facility is an integral part of the client's treatment and rehabilitation in seven out of seven client records reviewed. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
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 a review of the client records, the facility failed to document on the client treatment and rehabilitation plan that the work completed at the facility is an integral part of the client's treatment and rehabilitation in seven out of seven client records reviewed.
These findings were reviewed with the facility staff during the licensing process.
POC
Daystar was able to fix this issue on 2/2/2022. 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
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