INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on January 14, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, the facility failed to maintain the facility to be free from any danger to health and safety.
The findings include:
The exterior of the facility was inspected on January 15, 2013. There were cement steps that led to the front door. One of these steps was crumbling and the stone and cement texture was unsafe to walk on.
This was confirmed by the facility manager.
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Plan of Correction
Yellow caution tape is now blocking the top and bottom of these stairs as a warning to not use these stairs. Tape is in place as of 2/8/2013. Step will be restructured and re-faced within 90 days as soon as the weather is warm enough to provide the appropriate curing time free of ice and freezing temperatures for the concrete. Bi-weekly walkthroughs of the inside and outside of physical plant will be conducted by the Operations Manager and Executive Director to note any deficiencies. Operations Manager will schedule work to be done in consultation with the Executive Director
Operations Manager will oversee the work and facility will be in full compliance by 4/29/2013 |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the facility safe.
The findings include:
An inspection of the stairs leading to the third floor on January 15, 2013 identified torn carpet on the steps. The torn carpet was a safety hazard to the clients and staff using these stairs to go to the third floor bedrooms.
This finding was confirmed by the facility manager on January 15, 2013..
The facility had paint cans and a spray paint can stored in the basement area where clients have a recreational area and gym equipment.
This fire hazard was confirmed by the facility manager on January 15, 2013.
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Plan of Correction
Operations Manager scheduled and oversaw carpet replacement on 1/17/2013. Facility is in full compliance. Operations Manager and Executive Director will conduct bi-weekly walkthroughs of the inside and outside of the physical plant to insure deficiency does not recur.
Any work needed will be scheduled by the Operations Manager in consultation with the Executive Director and overseen by the Operations Manager |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on client record review, the facility failed to provide counseling services as stated on the treatment plan in three of five client records.
The findings include:
Five client records were reviewed on January 14, 2013. Counseling services are required to be provided to the client according to the treatment plan in five client records. The clients treatment plan stated that individual sessions would occur once per every fourteen days.
Client #3 had an individual session on November 11, 2012. The next session was December 6, 2012. There were twenty-five days between the individual sessions. Another individual session was completed on December 18, 2012. The next session session was completed on January 8, 2013. There was twenty-one days between the two individual sessions.
Client # 4 had a documented individual session on September 27, 2012. The next individual session was held on October 16, 2012. There was nineteen days between the individual sessions.
Client # 5 had an individual session on September 24, 2012. The next session was held on October 18, 2012. There were twenty-four days between the individual sessions.
The findings were confirmed by the Project/Facility Director on January 15, 2013.
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Plan of Correction
Staff have been in-serviced on the deficiency during the Treatment Team meeting on 1/17/2013. Clinical staff will make a client's next individual therapy appointment within the two week time frame as part of the conclusion of a client's current session.
Ongoing compliance will be monitored by the Compliance Officer through monthly random chart audits
Facility is in full compliance |