INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13 through 14, 2008 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 March 11, 2008.
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Plan of Correction
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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
Based on a February 13 through 14, 2008 review of training records, the facility failed to document 25 training hours in one of three records reviewed, #4. Employee #4 did not have any documentation of training hours for the last training year.
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Plan of Correction
P. Employee #4 had finished CAC required hours for renewed certification in previous yearand was under mistaken impression that 25 of those 50 hours would carry over into deficient training year.
I.Daystar will be in compliance by employee #4's hire date of 6/10/08 which will be the end of current training year for this employee.
D. Employee #4 has been registered for 12 hours of training by 3/14/08, and Executive Director will see that employee #4 completes an additional 13 hours before end of training year on 6/10/08 |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a February 14, 2008 inspection of facility grounds, the facility failed to ensure that three of fourteen garbage cans were covered with lids.
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Plan of Correction
P. Trash can lids are routinely stolen or destroyed and no notification given to Ops manager.
I. Daystar will purchase totes with permanently affixed lids or a dumpster by 4/20/2008
D. Ops manager will oversee purchase of items and insure continued compliance with standard. |
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 February 14, 2008 review of the fire drill record, the facility failed to conduct fire drills in two of nine months reviewed. Fire drills were not conducted in August and October 2007.
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Plan of Correction
P. In the two months without documented drills, one drill had taken place the week before the beginning of the month and one took place the week after the beginning of the other month
I. Daystar is currently in compliance.
D. Executive Director will check at each weekly staff meeting to determine when the monthly drill has taken place. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a February 13 through 14, 2008 review of employee records, the facility failed to ensure that work performance evaluations were completed according to the facility's time frame in three of six records reviewed, # 3, 4 and 6.
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Plan of Correction
P. One probationary period evaluation and two yearly evaluations were missed in the press of daily activities and deadlines.
I. All three evaluations were completed before the end of the licensure visit.
D. Executive Director has placed evaluation appointments in his Daystar calendar as uncancellable appointments except in the case of employee illness when the appointment will be moved to one week from the original scheduled date and time. |
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 February 13 through 14, 2008 review of facility policy and medication inspection records, the facility failed to adhere to their policy and procedure of monthly medication inspections. The medication area was only inspected quarterly instead of monthly.
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Plan of Correction
P. Daystar had moved to a quarterly inspection to meet the state standard without changing internal policy.
I. Internal policy change to quarterly med cabinet inspections approved by Board of Directors February 25, 2008. Policy will be re-written by Board of Director's meeting March 23, 2008
D. Executive Director will re-write policy and insure quarterly inspections. |