INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6 - 7, 2017 by staff from the Division of Drug and Alcohol Program Licensure. 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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704.11(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
The facility failed to document 12 clock hours of annual training in the project director's personnel record reviewed during the annual licensing inspection conducted on March 6 - 7, 2017.Employee # 1 has been the project director since the facility was licensed on June 30, 2015. Only 6 hours of annual training was documented for the January - December 2016 training year.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 will complete 12 hours of training during the first nine months of the program year (2017). The Clinical Director will be responsible for ensuring that all staff have the appropriate training during their annual personnel review. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document 25 clock hours of annual training in one of two counselor personnel records reviewed during the annual licensing inspection conducted on March 6 - 7, 2017.Employee # 4 was hired as a counselor on November 30, 2015. No training hours were documented for the January - December 2016 training year.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 will be in compliance with the 25 training hours per DDAP standard prior to year end 2017. Staff meeting April 15, 2017; Clinical Supervisor will conduct in-service training with clinical staff to review DDAP training requirements of 25 hours per calendar year. Clinical Director will audit each counselor's training hours in staff development log quarterly to ensure that each staff is on target for fulfillment of annual staff development quota of 25 hours annually as per DDAP requirement. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document fire extinguisher training upon staff employment in three of four personnel records reviewed during the annual licensing inspection conducted on March 6 - 7, 2017.Fire extinguisher training was not documented until February 27, 2017 for the following employees.Employee # 6 was hired on May 23, 2016.Employee # 7 was hired on August 9, 2016.Employee # 9 was hired on October 3, 2016.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the February 17 - 18, 2016 licensing inspection.
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Plan of Correction
The Training Coordinator shall ensure that all new hires receive "fire extinguisher" training within seven days of employment. The Training Coordinator and Clinical Supervisor shall meet on a weekly basis to ensure and coordinate the timely occurrence of trainings. A certificate of completed "fire extinguisher" training shall be placed in the individual's training file. |
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
The facility failed to document unannounced fire drills at least once a month based on fire drill records reviewed during the annual licensing inspection conducted on March 6 - 7, 2017.Fire drills were not documented for the months of July, August and September 2016.In addition, the March 2016 through February 2017 fire drill records did not include the exit route used, the number of persons in the facility at the time of the drill and whether or not the smoke detector or fire alarm was operative. The client's sleeping hours are from 11 PM to 6:30 AM. No fire drills were documented during these hours.The findings were reviewed with facilty staff during the licensing process.This is a repeat citation, pertaining to unannounced monthly fire drills, from the February 17 - 18, 2016 licensing inspection.
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Plan of Correction
Facilities Director will conduct unannounced fire drills on a monthly basis and during sleeping hours at least once every six months. Outcomes will be documented on newly formatted DDAP standard fire drill log. All newly hired staff will review DDAP standard 705.10 (d)(1)during fire drill orientation within first week of employment. Current staff will be re-trained on fire drill requirements by 4/30/2017. Clinical Director will audit fire drill log on a monthly basis to ensure compliance with DDAP Policy 705.10 (d)(1). |
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 staff performance evaluations for 2016 in five personnel records reviewed during the annual licensing inspection conducted on March 6 - 7, 2017.The facility was licensed on June 30, 2015. Employees # 1, 2 and 3 have worked at the facility since that date.Employee # 4 was hired on November 30, 2015.Employee # 5 was hired on December 1, 2015.The findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure that all annual employee performance
evaluations are done annually and in a timely manner.
The annual evaluations will be completed by 12/31/2017.
This will be monitored by the Clinical Director and Executive Director to ensure completion.
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709.28 (c) 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.
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Observations
The facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in eight of fourteen client records reviewed during the annual licensing inspection conducted on March 6 - 7, 2017. Urine/blood samples were submitted to a laboratory for analysis without a consent to release information or a qualified service organization agreement (QSOA) in the following client records.Client # 1 was admitted on March 1, 2017. The disclosure occurred on March 1, 2017. Client # 2 was admitted on January 9, 2017 and discharge on January 14, 2017. The disclosure occurred on January 9, 2017.Client # 3 was admitted on December 24, 2016 and discharged on December 28, 2016. The disclosure occurred on December 24, 2016.Client # 5 was admitted on February 28, 2017 and discharged on March 3, 2017. The disclosure occurred on February 28, 2017.Client # 6 was admitted on December 9, 2016 and discharged on December 13, 2016. The disclosure occurred on December 9, 2016.Client # 7 was admitted on August 19, 2016 and discharged on August 23, 2016. The disclosure occurred on August 19, 2016.The client's name, diagnosis and treatment information was released by fax to a drug and alcohol treatment provider without a consent to release information in the following client records.Client # 1 was admitted on March 1, 2017. The disclosure occurred on March 3, 2017. Client # 5 was admitted on February 28, 2017 and discharged on March 3, 2017. The disclosure occurred on March 3, 2017.The client's name, diagnosis and medication information was released by fax to a pharmacy without a consent to release information or QSOA in the following client records.Client # 9 was admitted to treatment on January 14, 2017. The disclosure occurred on March 1, 2017.Client # 13 was admitted to treatment on August 23, 2016 and discharged on October 12, 2016. The disclosure occurred on October 4, 2016.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 12, 2017 Clinical Supervisor will conduct training with clinical staff to review critical elements necessary for a properly documented consent form as per DDAP regulations. Clinical Director will conduct chart audits on a biweekly basis to ensure compliance. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facilty's physician failed to authenticate verbal orders in writing in three of fourteen client records reviewed during the annual licensing inspection conducted on March 6 - 7, 2017.The following clients were in the detoxification level of care and a verbal order was given for the following meds: Bentyl 20 mg, Vistaril 20 mg, Clonidine .1 mg and Librium 25 mg. Written authentication was not documented within 24 hours.Client # 1 was admitted March 1, 2017. The verbal order was given March 1, 2017.Client # 5 was admitted February 28, 2017 and discharged on March 3, 2017. The verbal order was given February 28, 2017.The following client was in the residential level of care and a verbal order was given for Vivitrol 380 mg on October 4, 2016. Written authentication was not documented within 3 business days.Client # 13 was admitted August 23, 2016 and discharged on October 12, 2016.The findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
Physicians and Nurses will be re-trained by the Nurse Manager on proper documentation of verbal orders including the signing and dating by physician within 24hours. This will be completed by 4/18/2017. Nurse manager will conduct chart audits on a weekly basis to ensure compliance. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facilty failed to document quarterly inspections of the medication storage areas based on a physical plant inspection and staff interviews conducted on March 7, 2017 at approximately 10:30 AM.No quarterly inspections were documented from March 2016 through March 7, 2017.The facilty's nursing staff confirmed that no inspections of the medication storage areas were documented.
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Plan of Correction
Nurse Manager will conduct quarterly inspections on the medication storage areas with newly devised DDAP standard checklist beginning 4/10/2017. Clinical Director will review checklist on a quarterly basis to ensure compliance. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
The facility failed to document a complete client record in five of seven residential client records reviewed during the annual licensing inspection conducted on March 6 - 7, 2017.Follow-up information was not documented within seven days of discharge, as per the facility's policy. In addition, verification that work done by the client at the project was an integral part of his/her treatment plan was not documented in the following client records.Client # 10 was admitted on January 10, 2017 and discharged on January 31, 2017.Client # 11 was admitted on December 14, 2016 and discharged on January 4, 2017.Client # 12 was admitted on August 23, 2016 and discharged on September 13, 2016.Client # 13 was admitted on August 23, 2016 and discharged on October 12, 2016.Client # 14 was admitted on September 29, 2016 and discharged on October 21, 2016.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the current policy and procedure that addresses follow-up contact on all clients discharged from each level of care within seven days with the Counselors and Detox Specialist. The Counselors and Detox Specialist will make sure that follow-up calls are placed within the appropriate time frame. All treatment goals will address any work therapy goals that may be listed in the client's treatment plan.
The client's clinical therapist, in conjunction with the client, will develop the client's treatment plans, goals, and objectives. There will be specific work therapy goals listed within the client's treatment plan.
The Clinical Supervisor will monitor for compliance by completing monthly chart audits. Target date for final completion is 4/14/2017. |