INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 26 through 27, 2011 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on February 23, 2011.
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Plan of Correction
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs and an interview with the project director, the facility failed to document the completion of monthly unannounced fire drills.The findings include:A review of the fire drill logs was conducted on January 26, 2011. There was no documentation that a fire drill was conducted for the month of July 2010. An interview was conducted with the project director on January 26, 2011 at 2:30 p.m., which confirmed that there was no documentation of a fire drill in July 2010.
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Plan of Correction
Coordination of Fire Drills has been taken over by the new Operations Manager who is in charge of the physical plant and will ensure compliance by creating a master calendar with scheduled dates and times for drills. Fire drill log will be reviewed by the executive director at the beginning of the last week of each month to insure that a drill has taken place for that month |
709.32(a) LICENSURE Medication Control
709.32. Medication control.
(a) Projects which furnish pharmaceutical services shall comply with all applicable Federal, State and local ordinances, statutes and regulations regarding the storing, compounding, administering or dispensing of medication.
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Observations
Based on review of the policy and procedure manual and an interview with the project director, the facility failed to have a current policy and procedure in place for furnishing pharmaceutical services. The findings include:On January 26, 2011, the facility policy and procedure manual was reviewed. The policy stated that the facility does not supply pharmaceutical services and they do not order medications. However, based upon client record reviews and an interview with the project director on January 27, 2011, the facility does utilize See Right Pharmacy to order client medications and the pharmacy also delivers the medications to the facility. The facility does have a doctor on staff who will write medication prescriptions. This information was confirmed by the project director.
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Plan of Correction
Operations manual has been updated as of 2/9/2011 to read:
709.32 MEDICATION CONTROL
Daystar does not provide pharmaceutical services, but does order client medications through the See-Right Pharmacy, and securely stores prescribed medications. Daystar has a contractual agreement with a physician who periodically will see clients to prescribe, review, and adjust medications or for other health related concerns. Policy on Medication control has been written and appears here.
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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility director, the facility failed to document inspections of the medication storage area, as required by regulation.The findings include:The regulation requires an inspection of the medication storage area. On January 26, 2011, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an inspection of the medication storage area will be completed and documented quarterly by staff. Inspections were reviewed for the months of January 2010 to December 2010. The facility failed to document the quarterly inspection for April, May and June 2010. The facility director confirmed that medication storage area inspections were not documented for the quarter identified above.
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Plan of Correction
Quarterly medication storage area inspections have been added to the Executive Director's master calendar and compliance will be monitored by both the Executive Director and the Operations Manager |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in four of four client records, as required.The findings include:Eight client records were reviewed on January 27, 2011. Case consultations were required in four of the eight client records. The facility policy states case consultations are completed every 90 days. The facility did not document case consultations in client records # 2, 4, 5, and 6. An interview with the project director on January 28, 2011 confirmed the consultations were not completed.Client # 2 was admitted on September 10, 2010 and was discharged on December 13, 2010. The case consultation was due December 10, 2010. No documentation of a case consultation was included in the client record.Client # 4 was admitted on April 6,2010 and was discharged on July 9, 2010. The case consultation was due July 6, 2010. No documentation of a case consultation was included in the client record. Client # 5 was admitted on October 19, 2010. The case consultation was due January 19, 2011. The client remains in treatment. To date no documentation of a case consultation was included in the client record. Client # 6 was admitted on October 20, 2010. The case consultation was due January 20, 2011. The client remains in treatment. To date no documentation of a case consultation was included in the client record.
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Plan of Correction
All consultations have been completed. Facility is in full compliance and the new counselor who begins employment 2/17/2011 will ensure compliance with oversight from the Executive Director and the part-time therapist who will conduct random chart audits at least once a month |
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 the review of client records, the facility failed to document a discharge summary within one week of discharge in two of four discharge records reviewed. Additionally, the facility failed to document the reason for treatment in two of four discharge summaries.The findings include:Client records were reviewed on January 28, 2011. The facility failed to document a discharge summary within one week of discharge in client records # 3 and 4. Client # 3 was admitted on September 16, 2010 and discharged on November 3, 2010. The discharge summary was due by November 10, 2010. The discharge summary was not documented until November 22, 2010.Client # 4 was admitted on April 6, 2010 and discharged on July 9, 2010. The discharge summary was due by July 16, 2010. The discharge summary was not documented until August 24, 2010. In client records # 2 and 4, the facility failed to include the reasons for the client entering treatment on the discharge summary.
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Plan of Correction
discharge summaries are now being fully completed within the established time frame of the standard. New counselor who starts employment 2/17/2011 will be trained in the importance of keeping the timeline of the standard. Compliance will be ensured by Executive Director and part-time therapist through monthly random chart audits |