INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18-19, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, DARS, Inc Supervised Independent Living Program 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 (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
Based on a review of five personnel records, the facility failed to provide documentation of all staff being instructed on the use of the fire extinguisher upon employment.
Employee # 4 was hired as a support staff on December 19, 2022 and promoted to counselor on May 1, 2023 and was still in this position at the time of the inspection. Fire extinguisher training was not documented to have occurred until January 13, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All newly hired staff are required to complete fire extinguisher training within the first week of employment as part of the new hire orientation.
Employee #4 did not complete this training during this initial period due to their limited availability to be scheduled during the first months of employment.
Effective 9/21/23, the Training Coordinator will ensure that all newly hired staff have completed fire extinguisher training and the documentation is placed in the employee's training file before they are eligible to be placed on the shift schedule.
This will be maintained through documentation from the Training Coordinator and communication with the Intermediate Shift Supervisor. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of five personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies upon employment.
Employee # 4 was hired as a support staff on December 19, 2022 and promoted to counselor on May 1, 2023 and was still in this position at the time of the inspection. Training to perform assigned tasks during emergencies was documented to not have occurred until January 13, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/21/23, all newly hired staff will be required to have completed all trainings on emergency procedures as outlined in the New Employee Training Checklist before the employee is eligible to be scheduled for shifts.
This documentation will be maintained by the Training Coordinator and filed in the employee's training file.
Adherence to this policy will be maintained through documentation by the Training Coordinator and communication with the Intermediate Shift Supervisor. |
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.
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Observations
Based on the review of the facility's fire drill log for the months of September 2022 through August 2023, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was no documentation of overnight fire drills provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/22/23, the daily schedule of the SIL program has been adjusted to reflect that the wake-up time for clients starts at 6:30am. The previous schedule indicated the wake-up time of 6:00am, however, due to the start time for the school day, this was adjusted to 6:30am to allow clients additional time to sleep.
All fire drills completed during sleeping hours will be conducted at least every six months and will take place before 6:30am.
This will be documented in the Fire Drill log book by the Staff Supervisor and will be monitored by the Program Operations Supervisor. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on seven of eight client records reviewed, the facility failed to provide a complete client record to include information relative to the client ' s involvement with the project that included individualized group therapy progress notes. The group therapy notes reviewed did not include a comment relative to each individual ' s response or participation in the group session.
Client #1 was admitted on September 6, 2023 and was current at the time of the inspection.
Client #2 was admitted on May 23, 2023 and was current at the time of the inspection.
Client #3 was admitted on April 6,2023 and was current at the time of the inspection.
Client #4 was admitted on September 6, 2023 and was current at the time of the inspection.
Client #6 was admitted on December 1, 2022 and discharged on January 19, 2023.
Client #7 was admitted on October 4, 2022 and discharged on March 10, 2023.
Client #8 was admitted on September 8, 2022 and discharged on October 7, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/22/23, all group therapy notes must include a hand-written assessment for the individual client.
Group notes may be copied to reflect the content of the group discussion/activity, but the assessment section will be completed in writing to eliminate the possibility of group notes being reproduced for multiple clients without comment relative to each individual's response/participation in the group session.
This will be monitored for compliance by the Clinical Director during clinical supervision sessions and internal chart audits on a monthly basis. |