INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 29, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure each counselor met the qualifications of the position at the time of hire in in two of five applicable personnel records reviewed.Staff #3 was hired as a recovery assistant on February 13, 2023, promoted to a counselor assistant on July 17, 2023, and promoted to a counselor on October 6, 2024. Staff #3 did not meet the educational requirements to be a counselor. Staff #5 was promoted to a counselor on September 25, 2023. Staff #5 was previously reviewed and qualified with full certification as an addictions counselor by a statewide certification body. However, this certification lapsed March 2024 and was not renewed at the time of the inspection.This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinical Supervisor and HR Manager reviewed Qualifications and regulatory expectations for the position of counselor.
Staff #3 was moved to Counselor Assistant until they meet the qualifications for Counselor per 704.7 LICENSURE Counselor Qualifications.
Staff # 5 has applied for recertification on-line and is awaiting confirmation.
Plan of Correction
1. Review and Update Hiring Policies
- Action: Conduct a comprehensive review of the facility's hiring policies to ensure they align with state and federal regulations for counselor qualifications.
- Responsible Party: Human Resources (HR) Manager
- Timeline: Within 30 days
- Outcome: Updated hiring policies that clearly outline the educational and certification requirements for each counseling position.
2. Verification of Qualifications at Hiring
- Action: Implement a standardized process for verifying the educational qualifications and certifications of all new hires and promotions.
- Responsible Party: HR Department
- Timeline: Immediate and ongoing
- Outcome: All personnel records will include verified documentation of qualifications at the time of hire or promotion.
3. Educational Requirements for Staff #3
- Action: Assess the current educational qualifications of Staff #3 and determine the necessary steps to meet the counselor requirements.
- If Staff #3 is willing to pursue the required education, provide support and resources for them to obtain the necessary qualifications.
- Until Staff #3 can meet the requirements for Counselor, they will be reassigned to the position of Counselor Assistant, which matches their current qualifications.
- Responsible Party: Clinical Supervisor and HR Manager
- Timeline: Within 60 days
- Outcome: Staff #3 will either meet the educational requirements for their position or be reassigned appropriately.
4. Certification Renewal for Staff #5
- Action: Immediately assist Staff #5 in renewing their lapsed certification.
- Provide information on the renewal process and any required continuing education.
- Monitor the progress to ensure timely completion of the renewal.
- Responsible Party: HR Department and Staff #5
- Timeline: Within 30 days
- Outcome: Staff #5 will have an active certification as an addictions counselor.
5. Ongoing Monitoring and Compliance
- Action: Establish a system for regular monitoring of staff qualifications and certifications to ensure ongoing compliance.
- Schedule periodic audits of personnel records.
- Implement reminders for certification renewals.
- Responsible Party: HR Department
- Timeline: Ongoing
- Outcome: Continuous compliance with qualification and certification requirements for all counseling staff.
6. Training and Education
- Action: Provide training to supervisors on the importance of maintaining up-to-date qualifications and certifications.
- Responsible Party: HR Department
- Timeline: Within 45 days
- Outcome: HR staff and supervisors will be knowledgeable about qualification requirements and the importance of compliance.
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in four of five applicable staff records.Staff #3 was hired as a recovery assistant on February 13, 2023, promoted to a counselor assistant on July 17, 2023, and promoted to a counselor on October 6, 2024. The TB/STD training was to be completed by July 17, 2024, but was not completed until November 11, 2024.Staff #4 was hired as a recovery assistant on July 18, 2023, promoted to a counselor assistant on September 4, 2023, and promoted to a counselor on September 15, 2024. The TB/STD training was to be completed by September 4, 2024, but was not completed until November 11, 2024.Staff #6 was hired as counselor assistant on May 31, 2023 and promoted to a counselor on November 30, 2023. The HIV/AIDS and TB/STD trainings were to be completed by May 31, 2024. The HIV/AIDS training was completed on January 27, 2025. The TB/STD training was not completed at the time of the inspection.Staff #10 was hired as a counselor assistant on August 13, 2023. The HIV/AIDS and TB/STD trainings were to be completed by August 13, 2024. The HIV/AIDS training was completed on January 28, 2025. The TB/STD training was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
1. Training Plan Completion: Every staff member has a training plan that includes required training hours, mandatory trainings, and time frames.
2. Quarterly Evaluations: The HR Manager will conduct quarterly evaluations to ensure staff are meeting their annual training requirements.
3. Clinical Team Education: The clinical supervisor has educated the clinical team on the importance of maintaining necessary trainings.
4. New Hire Education: All newly hired staff will be informed about training requirements.
5. Specific Training for New Employees: The HR Manager will ensure new employees complete HIV/AIDS and TB/STD training within their first year.
Staff #6 will receive TB/STD training on May 28, 2025.
Staff #10 has resigned prior to taking TB/STD training
|
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.
|
Observations
Based on the review of the facility's fire drill log for the months of January 2024 through December 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. Overnight fire drills were conducted on March 8, 2024 and April 19, 2024. A fire drill was due by October 2024 and was not completed.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
1. Maintenance Supervisor Responsibilities:
- Addressed on protocols and proper documentation of fire drills.
- Will meet with the Project Director bi-monthly to review and schedule fire drills.
- Required to review drills with the clinical and medical staff monthly to ensure compliance with regulatory standards.
2. Training and Compliance:
- Maintenance staff trained on fire drill regulations and expectations, especially for sleeping hour fire drills.
- Facility will complete sleeping hour fire drills at least once every 6 months to comply with 705.10 (d) (5) regulations, effective immediately.
3. Audit and Review:
- Project Director and Maintenance Supervisor will audit fire drill records twice yearly to ensure they are completed and compliant.
These steps should help ensure that SpiritLife remains safe and compliant with regulations.
|
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on the review of the facility's fire drill log for the months of January 2024 through December 2024, the facility failed to utilize alternating exits during monthly fire drills.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Maintenance Supervisor was informed about the importance of properly documenting fire drills to comply with regulations.
It was noted that alternate routes were being used but not recorded.
Moving forward, the Maintenance Supervisor will review fire drills monthly to ensure accurate documentation and adherence to regulatory standards.
Plan of Correction
1. Assessment and Documentation
- Review Fire Drill Logs: Conduct a thorough review of the fire drill logs from January 2024 to December 2024 to identify patterns and specific instances where alternating exits were not utilized.
- Document Findings: Record the findings in a detailed report, highlighting the months and specific drills where the issue occurred.
2. Policy Update
- Revise Fire Drill Policy: Update the facility's fire drill policy to explicitly require the use of alternating exits during each drill. Ensure the policy includes clear instructions on how to alternate exits.
- Approval and Dissemination: Obtain approval from the facility's safety committee and disseminate the updated policy to all staff members.
3. Training and Education
- Conduct Training Sessions: Organize mandatory training sessions for all staff members to educate them on the importance of using alternating exits during fire drills. Include practical demonstrations and role-playing exercises.
- Training Materials: Develop and distribute training materials, such as handouts and visual aids, that outline the updated fire drill procedures and the importance of alternating exits.
4. Implementation and Monitoring
- Schedule Monthly Drills: Plan and schedule monthly fire drills, ensuring that different exits are used in each drill. Rotate the exits systematically to cover all possible evacuation routes.
- Assign Responsibilities: Designate specific staff members to oversee the implementation of the updated fire drill procedures and ensure compliance during each drill.
5. Evaluation and Continuous Improvement
- Post-Drill Evaluations: Conduct evaluations after each fire drill to assess the effectiveness of the evacuation process and the use of alternating exits. Gather feedback from participants and observers.
- Address Issues Promptly: Identify and address any issues or challenges encountered during the drills. Make necessary adjustments to the procedures and training as needed.
- Regular Audits: Schedule regular audits of the fire drill logs and procedures to ensure ongoing compliance with the updated policy.
6. Reporting and Accountability
- Report to Management: Provide regular reports to the facility's management team on the progress of the corrective actions and the outcomes of the fire drills.
- Accountability Measures: Implement accountability measures for staff members who fail to comply with the updated fire drill procedures.
7. Responsible Parties: Maintenance Supervisor and HR Manager
By following this plan, the facility can ensure that alternating exits are utilized during monthly fire drills, enhancing overall safety and preparedness.
|