INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for facility directors in employee #2's employee record.
Employee #2 was hired as a counselor on January 19, 2016 and promoted to facility director on June 1, 2018. The facility's training year that was reviewed was from July 1, 2019 through June 30, 2020. Employee #2's employee record did not show any training hours completed for the training year.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
704.11(d)(2) LICENSURE
Annual Training Requirements:
Employee Number 2 did not have all the required trainings for the training year2019-2020.
Daystar human resourses, as of 7/1/2020, began to review the facility quarterly to ensure complience with DDAP training regulations. Staff will be notified each quarteras to their training status. The facility training plan has been provided to all employees through eletronic records and all staff has access to their own file.
Daystar human resourses will inform staff on a quarterly basis to ensure compliance and the executive director will ensure overall compliance.
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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
Based on the review of client records, the facility failed to document a completed consent to release information form in one out of seven records reviewed.
Client #2 was admitted on June 22, 2020 and discharged on November 2, 2020. A consent to release form dated September 14, 2020 to and individual had "other" check marked for the purpose without indication of another purpose.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.28 (c) (3) LICENSURE
Confidentiality:
A consent in the file of client Number 2
was found to not be complete due to the check box "other" was left blank. On 3/4/2021 this problem was fixed by removing the check box other, in order to never miss checking the box. If there is a need to disclose "other" information, this will be hand written into the consent.
The program director will ensure conplience by monthly chart reviews and the executive director will ensure overall complience through weekly supervision. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to ensure that the client had been made aware of all their rights in seven out of seven records reviewed. The documentation of client rights presented to the client did not include that the clients have the right to submit rebuttal data or memoranda to their own records.
Client #1 was admitted on September 24, 2020 and discharged on December 11, 2020.
Client #2 was admitted on June 22, 2020 and discharged on November 2, 2020.
Client #3 was admitted on May 27, 2020 and discharged on September 1, 2020.
Client #4 was admitted on September 14, 2020 and discharged on January 15, 2021.
Client #5 was admitted on December 14, 2020 and was still active at the time of the inspection.
Client #6 was admitted on November 6, 2020 and was still active at the time of the inspection.
Client #7 was admitted on November 13, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.30 (6) LICENSURE
Client rights:
Daystar did not have a clear statement that clients have a right to submit rebuttal data or memoranda to their own records.
In 7 out 0f 7 charts reviewed this was not present. While the DDAP inspector was still here on 3/4/2021, Daystar staff ammended the client Right form to reflect that clients have a right to submit rebuttal data or memoranda to their own records.
The executive director will ensure overall complience. |