INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 21-22, and April 17-19, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspections, Spiritlife, Inc., was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served.
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Plan of Correction
Recruitment and hiring policy was revised on 4/25/2019 to address the recruitment and hiring of staff persons who are appropriate to the population served. Every effort will be made to hire staff persons representative of the population served. Program staff will continue to work with Human Resources in the recruitment and hiring of appropriate staff for the project. |
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
The facility failed to ensure that the facility was free from danger to health and safety of clients, staff and visitors.*The sidewalk in front of the counselor's building was broken/cracked which created a tripping hazard.
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Plan of Correction
The sidewalk landing outside of the counselor's building will be repaired no later than May 30th, 2019. Maintenance department will complete the task. The Maintenance Supervisor will oversee the project to assure completion no later than projected completion date. Physical plant walk throughs will be conducted on a monthly basis by the designated maintenance personnel along with all staff completing facility incidents reports to ensure needed repairs are addressed. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that hot water temperatures were maintained at 120 degrees or less.*The bathroom near the detox lounge was measured at 123.5 degrees*The bathroom in room 201 was measured at 124.7 degrees*The bathroom in room 207 was measured at 124.2 degrees*The bathroom in the administration building was measured at 127.8 degrees*The bathroom in the counseling building was measured at 124.5 degrees
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Plan of Correction
The Clinical Director met with the Head of Maintenance on 4/20/2019. Water temperature was adjusted to meet the regulation of 120 degrees or less. To ensure continued proper water pressure and temperature, the maintenance person will inspect the water temperature throughout the facility on a weekly basis and report any concerns to the clinical director immediately to rectify the situation. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
The facility failed to ensure that bathrooms were maintained in a functional, clean and sanitary manner.The bathroom in room #210 on the second floor, had water damage on the wall next to the bath tub.
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Plan of Correction
The bathroom in room #210 will be renovated around the bath tab no later than no later than June 1, 2019. Maintenance will complete task no later than June 1, 2019. Head of Maintenance will oversee project to ensure completion on or before June 1, 2019.
The program staff and maintenance department will monitor the cleanliness of the bathrooms and the members will continue with the weekly General Inspection (GI) of their living areas which includes the bathrooms.
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709.26 (b) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(1) Application or resume for employment.
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Observations
The facility failed to ensure that all staff had a personnel record.*At the time of investigation, the facility did not have a personnel record for staffs, #3 & 4.
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Plan of Correction
Clinical Director met with Human Resources and presented concerns for staff #3 and #4. Human Resources will update the personnel files to meet the standards on 709.26 (b) (1) no later than 5/3/2019. Clinical Director will oversee process on a monthly basis to assure compliance. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility policy failed to include the following elements with regard to client rights:(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. *Facility policy is missing: marital status, and sexual orientation.(3) Reasons for removing sections shall be documented in the record.
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Plan of Correction
On April 29, 2019 a review was completed of the Client Rights by the Clinical Director. At that time, the document was revised to include all regulations found in 709.30. This revised document was reviewed with all staff on April 29, 2019. All staff were provided with a revised version of the agencies Client Rights and directed to begin to immediately implement the revised document. In addition, the previous version of the Client Rights was removed from our document database and replaced with the revised version. The Clinical Supervisor, in the course of her weekly chart reviews, will ensure that the revised version of the Client Rights is being utilized by all staff. This concern will continue to be monitored by the Clinical Supervisor. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to have documented policy and procedures to the following unusual incidents for this regulation.1. Physical assault or sexual assault by staff or a client.2. Selling or use of illicit drugs on the premises.3. Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.4. Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.5. Theft, burglary, break-in or similar incident at the facility.6. Event at the facility requiring the presence of police, fire or ambulance personnel.7. Fire or structural damage to the facility.8. Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Plan of Correction
The Clinical Director will be responsible for creating policies that specifically address each unusual incident as outlined in 709.34 (a) by 4/25/19. The Executive Director will oversee the process project to assure completion. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
The facility failed to document that a prompt review of causes that were responsible for the unusual incident was conducted.11/25/2018 a client was taken to the hospital after an attempted suicide. The facility policy states that a ' root-cause analysis ' will be conducted for unusual incidents, which is in compliance with DDAP regulations. According to the facility staff a root cause analysis was not completed, and the incident was not reported to DDAP, as required.
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Plan of Correction
Effective immediately, It will be the policy of the Clinical Director and Clinical Supervisor to review the documentation included in the actual incident report along with all other available client records and possible statements taken from witness to the incident within 24 hours of incident.
The Clinical Director and Clinical Supervisor will identify the causes, both direct and indirect that potentially led up to the incident.
Where appropriate and indicated, a plan of correction will be developed and put into place within 72 hours of the incident.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility failed to have documented policy and procedures regarding the projects response to unusual incidents. The policy failed to specify: (c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (1) Physical or sexual assault by staff or a client. (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances. (3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day. (4) Event at the facility requiring the presence of police, fire or ambulance personnel. (5) Outbreak of a contagious disease requiring CDC notification.
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Plan of Correction
The D&A program has a written policy and procedure that specifically address unusual incident reporting and explicitly states that unusual incident reports are to be sent to the Department within 3 business days of the incident. In several instances, the protocol was not upheld. Effective immediately, all unusual incident reports will be submitted to the department via email as outlined per the regulation and procedure. The Clinical Director will be responsible for overseeing that this be upheld. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (4) Event at the facility requiring the presence of police, fire or ambulance personnel. the period from January 2018 through February 2019 there were twenty-seven events at the facility requiring an ambulance; the facility staff confirmed that these incidents were not reported to DDAP.
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Plan of Correction
These findings were reviewed with the Clinical Director and the Clinical Supervisor. Based on the review of these findings, SpiritLies's Incident Management Process was updated on 4/25/19 to include the notification of Unusual Incidents regardless of where the incident occurred. Effective immediately, SpiritLife will file a written unusual incident report with the Department within 3 business days following an unusual incident. This will be monitored and tracked by the Safety Committee during quarterly meetings. |
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
The facility failed to document that counseling was provided according to the treatment plan in client record #2. Client #2 was admitted on 11/7/18 and was discharged on 12/26/18.The comprehensive treatment plan dated 11/12/18 indicated that individual sessions would be provided one time per week, however there were no individual sessions documented from 11/13/18 through 12/11/18.
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Plan of Correction
Counselors are expected to meet with their clients 1 x a week as per policy and licensing. Each session is to be documented and recorded. The Clinical Supervisor conducted a clinical supervisory session with all the clinicians April 25, 2019 and reviewed the above information. The Clinical Supervisor will be responsible for conducting ongoing weekly and monthly audits on charts to ensure residents are receiving 1-1 session at least every seven days. The Clinical Director will be responsible for conducting weekly community meetings with all residents to receive feedback on them receiving weekly 1-1 sessions. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The facility failed to ensure that work done by the client is an integral part of the treatment and rehabilitation plan.* Client # 4 was admitted on 2/6/18 and discharged on 2/27/18. Client #4 performed work on a staff member's personal vehicle and this was not documented on the client's treatment plan or in progress notes as work therapy.
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Plan of Correction
Effective immediately, Counselors will ensure that all assigned chore functions serve a therapeutic purpose, designed to cultivate a specific recovery skill or character quality. Counselors will document work therapy as part of the client comprehensive treatment plan. In addition, general and specific job assignments will be documented on the client's individual note. The therapeutic purpose or rationale for the assignment shall be documented in the "plan" section. The Program Director and Clinical Supervisor will ensure compliance through monthly case audits and monthly supervision. |