INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 2 and 3, 2010 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 6, 2010.
|
Plan of Correction
|
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
|
Observations
Based on a review of personnel records, and an interview with the project director, the facility failed to document the results of a reference investigation in one of four personnel records reviewed.The findings include:Four personnel records were reviewed on February 2, 2010. Personnel record # 2 did not include the results of a reference investigation.Employee # 2 had been hired on September 1, 2009, the project director advised the inspectors that he had not yet completed a reference investigation for employee # 2.
|
Plan of Correction
Reference gathering will be done by the Executive Director for employee #2 by 3/31/2010. Compliance will be maintained by the Administrative Assistant. Facility will be in full compliance with the standard by 3/31/2010 |
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.
|
Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in accordance with facility policy and procedure in three of three personnel records.The findings include:Per facility policy and procedures employees are to receive their performance evaluation on their anniversary date.Four personnel records were reviewed on February 2, 2010. Annual staff work performance evaluations were required in three personnel records. The facility failed to document timely annual staff work performance evaluations in personnel records # 1, 3, and 4.Employee # 1 was hired on March 1, 2006. The annual work performance evaluation for 2009 was due by March 1, 2009. The annual work performance evaluation was documented on June 29, 2009.Employee # 3 was hired on June 10, 2002. The annual work performance evaluation for 2009 was due by June 1, 2009. The annual work performance evaluation was documented on January 28, 2010. There was no verification that an evaluation had been conducted in 2009.Employee # 4 was hired on July 13, 2006. The annual work performance evaluation for 2009 was due by July 13, 2009. The annual work performance evaluation was documented on February 1, 2010. There was no verification that an evaluation had been conducted in 2009.
|
Plan of Correction
A Master Calendar for 2010, including due dates for each employee's annual evaluation, has been developed by the Executive Director at the direction of the Personnel Committee of the Board of Directors. Administrative Assistant will ensure on-going compliance with the standard. Facility will be in full compliance by 3/31/2010 |
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.
|
Observations
Based on a tour of the facility's physical plant, the facility failed to ensure the building's grounds were safe and in good repair at all times. The findings include:The facility's physical plant was inspected on February 3, 2010. During this inspection it was found that about one third of a stair was missing. Specifically, the second step from the ground on the exterior stairway leading from the sidewalk to the front porch. The stairs are composed of cement. The damaged stair poses a threat to to the safety and well being of the residents, employees, and visitors of the facility.
|
Plan of Correction
Stair will be repaired by 5/31/2010. Operations Manger will monitor compliance with physical plant standards. Facility will be in full compliance by 5/31/2010 |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
|
Observations
Based on an inspection of the physical plant, the facility failed to provide documentation that cold food is kept at or below 40 degrees Fahrenheit , hot food at or above 140 degrees Fahrenheit, and frozen food at or below 0 degrees Fahrenheit.The findings include:The physical plant was inspected on February 3, 2010. The thermometer on the refrigerator read 37 degrees Fahrenheit during the inspection, however the facility does not keep a temperature log for this refrigerator, the freezer or the serving temperatures for the food.
|
Plan of Correction
Temperature logs for all refrigerators and freezers is kept at the monitor's desk in the main office and is up to date. The Senior House Monitor will place pages logging serving temperatures of food into the log. Ongoing compliance will be monitored by the Senior House Monitor. Facility will be in full compliance with the standard by 3/31/2010 |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the fire drill record log, the facility failed to document nine monthly fire drills in the last year. The findings include: The fire drill record log was reviewed on February 2, 2010. The log was reviewed from December 2008 to January 2010. Nine of those months did not list documentation that a fire drill was conducted. Drills had been conducted for January 09, June '09, October '09, and December 09. All other months were missing.
|
Plan of Correction
The Executive Director has created a master calendar for fire drills for 2010 including date and specific shift or time of day drill is to take place. Senior House monitor will ensure ongoing compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document frequency of treatment in five of five client records.The findings include:Six client records were reviewed in February 3, 2010. Treatment plans were required in five of the six client records. The facility did not document frequency in the treatment plans documented in client records # 1, 2, 3, 4 and 6.
|
Plan of Correction
Treatment Plan forms were corrected during licensure visit. New forms will be placed in new client charts by the Senior House Monitor. Old forms have been destroyed. The new forms were reviewed with staff during the 2/25/2010 staff meeting. Facility is in full compliance with the standard. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of the facility's policies and procedures and three client records, the facility either completed the treatment plan update late, not at all, or did not report progress on goals in three of three records reviewed.The findings include:Six client records were reviewed on February 3, 2010. Treatment plan updates were required in three client records. Client record #3's previous treatment plan update was completed on December 12, 2009. Facility policy states that a treatment plan update must be completed every 30 days. The next update was due on January 12, 2010. The most recent treatment plan update was completed on January 20, 2010. Client record #4 had a comprehensive treatment plan completed on December 24, 2009. The record did not include a treatment plan update for January 2010. Client record #2's treatment plan update was missing documentation regarding the client's progress as it relates to specific goals identified in the comprehensive treatment plan.
|
Plan of Correction
The standard was reviewed with staff during the 2/25/2010 staff meeting. Full time Counselor will ensure compliance with oversight from the Executive Director. Charts will be jointly reviewed by the Executive Director and the Full time Counselor during the supervision meeting in the last week of each month. |
709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
|
Observations
Based on a review of the facility's letters of agreement and an interview with the project director, the facility failed to assist clients in obtaining legal services when necessary.The findings include:On February 3, 2010 letters of agreement were reviewed. There was no documentation of a letter of agreement for legal services. When the project director was asked if the facility had a letter of agreement for legal services or documentation in any of the client records of a referral for legal services, the project director stated they did not.
|
Plan of Correction
Clients requiring legal services are referred to agencies listed in the Dauphin County Resource Directory and the Contact 2010 Resource Directory for our area. Daystar will pursue a referral agreement for legal services for clients. A record of referrals made on behalf of clients will be placed in the client chart under the case management tab. The Case manager will monitor compliance. Facility will be in full compliance by 6/16/2010 |
709.52(e)(4) LICENSURE Economic support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
|
Observations
Based on a review of the facility's letters of agreement and an interview with the project director, the facility failed to assist clients in obtaining economic services when necessary.The findings include:On February 3, 2010 letters of agreement were reviewed. There was no documentation of a letter of agreement for economic services. When the project director was asked if the facility had a letter of agreement for economic services or documentation in any of the client records of a referral for economic services, the project director stated they did not.
|
Plan of Correction
Clients requiring economic support receive in-house budgeting training and are referred to agencies listed in the Dauphin County Resource Directory and the Contact 2010 Resource Directory for our area. Daystar will pursue a referral agreement for economic services for clients. A record of referrals made on behalf of clients will be placed in the client chart under the case management tab. The Case manager will monitor compliance. Facility will be in full compliance by 6/16/2010 |
709.51(e)(5) LICENSURE Educational support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
|
Observations
Based on a review of the facility's letters of agreement and an interview with the project director, the facility failed to assist clients in obtaining educational services when necessary.The findings include:On February 3, 2010 letters of agreement were reviewed. There was no documentation of a letter of agreement for educational services. When the project director was asked if the facility had a letter of agreement for educational services or documentation in any of the client records of a referral for educational services, the project director stated they did not.
|
Plan of Correction
Clients requiring educational support are referred to agencies listed in the Dauphin County Resource Directory and the Contact 2010 Resource Directory for our area. Daystar will pursue a referral agreement for educational services for clients. A record of referrals made on behalf of clients will be placed in the client chart under the case management tab. The Case manager will monitor compliance. Facility will be in full compliance by 6/16/2010 |
709.52(e)(6) LICENSURE Vocational Support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
|
Observations
Based on a review of the facility's letters of agreement and an interview with the project director, the facility failed to assist clients in obtaining vocational services when necessary.The findings include:On February 3, 2010 letters of agreement were reviewed. There was no documentation of a letter of agreement for vocational services. When the project director was asked if the facility had a letter of agreement for vocational services or documentation in any of the client records of a referral for vocational services, the project director stated they did not.
|
Plan of Correction
Clients requiring vocational support are assisted in-house with resume development and job-search training. An informal network of current staff and graduates of our program post hiring notices for our clients. Clients are also referred to OVR, CEED and the Job Center. Daystar will pursue a referral agreement for vocational services for clients. A record of referrals made on behalf of clients will be placed in the client chart under the case management tab. The Case manager will monitor compliance. Facility will be in full compliance by 6/16/2010 |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on the review of client records, the facility failed to document the dates when follow-ups were completed in two of two client records.The findings include:Eight records were reviewed on February 2 through 3, 2010. Follow-up information was required in two client records. The facility did not document the dates in which follow-ups had been conducted in client records #7 and 8.
|
Plan of Correction
Client Follow-up is kept separate from the client record in the Client Follow-up book. Contact with clients who are no longer at the facility is documented there. The form will be updated by the Case manager to include the date when contact is made. This standard was reviewed with staff at the 2/25/2010 staff meeting. The Administrative Assistant will monitor compliance. Facility will be in full compliance by 3/17/2010 |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document an overall plan for addressing training needs, as required by regulation.The findings include:On February 2, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, a training plan will be completed which addresses staff training needs, training subjects, trainers and propsed dates of training. The facility did provide a 2010 training plan but it lacked course descriptions, resources, and time frames.
|
Plan of Correction
The Executive Director will revise the 2010 agency training plan to include course descriptions, resources and time frames. The facility will be in full compliance by May 31, 2010 |
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 personnel records the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff. The findings include: On February 2, 2010 six personnel records were reviewed. The facility failed to document the required training hours in two of six personnel records.Staff #5 was hired on June 1, 2007, HIV/AIDS training was due by June 1, 2009. As of the licensing inspection, there was no documentation of this training. Staff #6 was hired on April 1, 2001, HIV/AIDS training was due by April 1, 2003. As of the licensing inspection, there was no documentation of this training.
|
Plan of Correction
Staff #5 Will receive the required training on 3/31/2010 through the Gaudenzia Training Institute
Staff #6 received 6 hours of HIV/AIDS training 4/6/02. This is documented in the employee's personnel file.
|
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.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records reviewed.The findings include:Two personnel records were reviewed on February 2, 2010. Personnel record # 4, did not have any documented training hours for training year 2008/2009. This is a repeat deficiency from the last licensing inspection for this specific counselor.
|
Plan of Correction
Staff #4's caseload has been removed pending submission of a corrective action plan for the attainment of 25 training hours by the end of our current training year and the completion of 16 of those hours before returning to counseling. The administrative assistant will monitor compliance. Facility will be in full compliance by 12/31/2010 |