INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 6 - 7, 2017 licensure renewal inspection. The follow-up inspection was conducted on September 28, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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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 a fire drill record including the exit route used, the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative based on the March - September 2017 fire drill records reviewed on September 28, 2017.
The exit route used was not documented for the following fire drills: 3/8/17, 4/28/17, 5/21/17, 6/28/17, 7/11/17, and 9/12/17.
The number of persons in the facility at the time of the drill was not documented for the following fire drills: 4/28/17, 5/21/17, 7/11/17, 8/16/17, 8/23/17 and 9/12/17.
Whether the fire alarm or smoke detector was operative was not documented for the following fire drills: 3/8/17, 4/28/17, 5/21/17, 6/28/17 and 9/12/17.
The findings were reviewed with facility staff during the inspection.
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Plan of Correction
Fire drill log was updated to include the exit route, the number of persons in the facility during the time of fire drill, and whether the smoke detector was operative. The director of operations will conduct monthly fire drill and ensure proper documentation.
Monthly safety meetings will ensure compliance with DDAP Policy 705.10 (d)(1)
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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.
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.
This plan of correction was not yet due as of the date of the plan of correction follow-up inspection on September 28, 2017.
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Plan of Correction
The Executiv 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. |
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 five residential client records reviewed on September 28, 2017.
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 # 4 was admitted on August 22, 2017 and discharged on September 17, 2017.
Client # 6 was admitted on August 25, 2017 and discharged on September 15, 2017.
Client # 7 was admitted on August 11, 2017 and discharged on August 16, 2017.
Client # 8 was admitted on August 11, 2017 and discharged on August 31, 2017.
Client # 9 was admitted on August 22, 2017.
Follow-up information was not documented within seven days of discharge, as per the facility's policy in the following client records.
Client # 7 was admitted on August 11, 2017 and discharged on August 16, 2017.
Client # 8 was admitted on August 11, 2017 and discharged on August 31, 2017.
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. on 11/01/2017. 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. Tx plans were revised to reflect work goals. Clinical Supervisor will conduct bi-weekly chart audits to ensure compliance. |