INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26-28, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to ensure that each counselor met the qualifications for the position in two of two personnel records.
Seven personnel records were reviewed on February 26-28, 2019. Two personnel records were reviewed as new hires and were required to have documentation of the qualifications for the position of counselor. Personnel records # 6 and 7 did not meet the requirements of a counselor.
Employee # 6 was hired as a counselor on January 18, 2019. The employee had only 3 months of clinical experience documented .
Employee # 7 was hired as a counselor on October 22, 2018. The employee had only 3 months of clinical experience documented .
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor updated Personnel records #6 and #7 with job descriptions for Counselor Assistants on 3/4/19 and educated both staff members on minimum requirements for counselor position. Clinical Supervisor will continue to work with Employee #6 and Employee #7 and document weekly intensive supervision. Employee #6 will meet one year of experience by January 18, 2020. Employee #7 will meet one year of required experience July 22, 2019. Clinical Director will ensure intensive supervision is occurring and documented on a weekly basis by Clinical Supervisor. Minimum requirements for counselor position updated with Human Resources effective 3/1/2019 to ensure compliance with state regulations. Executive Director and Clinical Director will ensure all current and future hires meet minimum requirements designated for each position. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to document feedback information.
Seven personnel records were reviewed on February 26-28, 2019. Five personnel records were reviewed for training feedback documentation.
Personnel records # 1, 2, 3, 4 and 5 were missing documentation of training feedback.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training feedback form was created and distributed to each department on 3/1/2019 with a comprehensive list of questions to evaluate the quality and the relevance of the training to their position within Spiritlife. Training evaluations will be stored in employee personnel files and evaluated yearly as part of the training evaluation and needs assessment. |
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
The facility failed to document an overnight fire drill at least once every six months.
The fire drill logs for the period of April 2018 to January 2019 were reviewed on February 26-28, 2019. An overnight fire drill was documented on April 20, 2018. There were no other overnights documented for the time period reviewed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 22 - 23, 2018 annual licensing inspection.
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Plan of Correction
The Maintenance Supervisor will schedule a fire drill to occur during sleeping hours at a minimum of one time quarterly. Maintenance Supervisor will be on site conducting the overnight fire drills. These drills will be documented in compliance with the regs with special attention to AM/PM designation as well as exits used.
The fire drill log will be reviewed by the Clinical Director and safety committee on a monthly basis to ensure compliance. |
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
The facility failed to document annual performance evaluations in three of five personnel records.
Seven personnel records were reviewed on February 26-28, 2019. Five personnel records required documentation of an annual evaluation review.
Annual evaluations were not documented for personnel records # 1, 2 and 3.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Human Resources was made aware of the missing annual performance evaluations and is developing a system within the agency to create reminders for department heads to complete annual evaluations. System will go into effect no later than March 29, 2019 and all department heads will be notified by Human Resources via email monthly on upcoming performance evaluations for staff. Executive Director will monitor Human Resources for progress on notification system as well as completion of performance evaluations monthly. Personnel files #1, #2,and #3 will have evaluations completed by March 29, 2019 by their designated department heads. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to obtain an informed and voluntary consent from the client that included the specific information to be disclosed in three of fifteen client records.
Fifteen client records were reviewed on February 26-28, 2019. All fifteen client records required documentation of consents. Client records # 2, 5 and 9 were missing the required information.
Client record # 2 had three separate consents to release information, all dated February 23, 2019, that did not document the specific information to be disclosed.
Client record # 5 had two separate consents to release information, both dated Janaury 4 , 2019, that did not document the specific information to be disclosed.
Client record # 9 had a consent to release information, dated February 1, 2019, that did not document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility clinical supervisor and nursing supervisor will retrain all staff responsible for completion of releases on the appropriate completion with special focus on documenting specific information to be released and utilization of informed and voluntary client consent to release information forms.
Facility clinical supervisor and nursing supervisor will monitor weekly during regular client chart reviews beginning on 3/26/19 to ensure ongoing 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to obtain an informed and voluntary consent from the client that included the purpose in five of fifteen client records.
Fifteen client records were reviewed on February 26-28, 2019. All fifteen client records required documentation of consents. Client records # 2, 5, 8, 9 and 14 were missing the required information.
Client record # 2 had four separate consents to release information, all dated February 23, 2019, that did not document the purpose.
Client record # 5 had a consent to release information, dated Janaury 4 , 2019, that did not document the purpose.
Client record # 8 had a consent to release information, dated February 5, 2019, that did not document the purpose.
Client record # 9 had a consent to release information, dated February 1, 2019, that did not document the purpose.
Client record # 14 had a consent to release information, dated November 14, 2018, that did not document the purpose.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor and Nursing Supervisor will hold an in service with department staff to train on policy and procedure for completion of releases of information. Clinical and Nursing Supervisors will meet individually with staff members responsible for charts #2,#5,#8,#9,and #14, to go over deficiencies and train on proper procedures for filling out releases by 4/1/19.
Facility clinical supervisor and nursing supervisor will monitor weekly during regular client chart reviews beginning on 3/26/19 to ensure ongoing 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
The facility failed to document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services, in four of seven client records.
Fifteen clients records were reviewed on February 26-28, 2019. Seven client records were reviewed as inpatient client records. Client records # 10, 13, 14 and 15 did not document the type and frequency of treatment and rehabilitation services.
Client # 10 had an individual treatment and rehabilitation plan completed on January 23, 2019. The plan was missing the type and frequency of services.
Client # 13 had an individual treatment and rehabilitation plan completed on December 31, 2018. The plan was missing the type and frequency of services.
Client # 14 had an individual treatment and rehabilitation plan completed on Novemeber 16, 2018. The plan was missing the type and frequency of services.
Client # 15 had an individual treatment and rehabilitation plan completed on November 14, 2018. The plan was missing the type and frequency of services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will train all clinical staff to complete treatment plans to ensure that type of services and frequency of services are documented on a consistent basis. Clinical Supervisor will conduct bi-weekly chart audits to monitor process. Clinical Supervisor will meet with staff responsible for chart #10, #13, #14, and #15 to go over deficiencies and ensure proper documentation of type and frequency of services. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
The facility failed to document an individual treatment and rehabilitation plan that included the support services, in four of seven client records.
Fifteen clients records were reviewed on February 26-28, 2019. Seven client records were reviewed as inpatient client records. Client records # 10, 11, 13 and 14 did not document support services.
Client # 10 had an individual treatment and rehabilitation plan completed on January 23, 2019. The plan was missing support services.
Client # 11 had an individual treatment and rehabilitation plan completed on December 6, 2018. The plan was missing support services.
Client # 13 had an individual treatment and rehabilitation plan completed on December 31, 2018. The plan was missing support services.
Client # 14 had an individual treatment and rehabilitation plan completed on Novemeber 16, 2018. The plan was support services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will train all clinical staff to complete treatment plans to ensure that support services are included in treatment plans. Clinical Supervisor will conduct bi-weekly chart audits to monitor process. Clinical Supervisor will meet with staff responsible for chart #10, #11, #13, #14, and #15 to go over deficiencies and ensure proper documentation of type and frequency of services. |