INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on January 23, 2020. Based on the findings of the on-site inspection, Daystar Center for Spiritual Recovery was found to not 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 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
During a physical site inspection on January 23, 2020, the residential facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
One stairway that was used for an exit from the second to the first floor had frayed carpeting that was a tripping hazard.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#: P105
705.10 (a) (1) (i) Licensure
Fire Safety:
Daystar Center removed frayed carpeting on 1/27/2020 in order to eliminate trip hazard. Monthly maintenance checks will be completed to ensure safety.
Daystar Maintenance staff and house manager will inspect facility to ensure compliance with fire safety regulations and identify any trip hazards or unsafe issues in the facility. The executive director will ensure overall compliance.
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709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
During a review of seven client records on January 23, 2020, the project failed to obtain an informed and voluntary consent from one client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to include the date, event or condition upon which the consent will expire.
Client #4 was admitted on October 11, 2019 and was current at the time of the inspection. Client #4 had an authorization to a pharmacy that did not include an expiration date.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
#: 0287
709.28 (c) (6)
Confidentiality:
The consent to the pharmacy was corrected on 1/25/2020 to include an expiration date by client #4's counselor.
The program director inspects all client charts monthly but due to this deficiency the admission consents will be checked weekly by the program director and the executive director will ensure overall compliance.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
During a review of seven client records on January 23,2020, the project failed to offer a copy of a client consent to the client and a copy maintained in one client record.
Client #4 was admitted on October 11, 2019 and was still current at the time of the inspection. An authorization to a pharmacy did not indicate whether a client was offered a copy of their consent.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
#: 0289
709.28 (d)
All clients are asked on admission to check the box to receive a copy or decline a copy of all consents. In the client #4 chart not box was checked. The consent was corrected on 1/25/2020. The client checked the box to decline a copy of this consent.
The program director will inspect all client charts monthly but due to this deficiency the admission consents will be checked weekly by the program director and the executive director will ensure overall compliance.
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709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
During a review of policies and procedures on January 23, 2020, the project failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights to include that clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with the project during the licensing process.
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Plan of Correction
#: 0307
709.30 (6)
Client rights:
The client rights documentation, that all clients sign on admission, at time of inspection states, "You have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from your records. The request must be in writing to the Executive Director and will include reasons why you feel the information is inappropriate".
The client rights have been revised on 2/25/2020 to state "You have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from your records and you have the right to submit rebuttal data or memoranda to your own client record. The request must be in writing to the Executive Director and will include reasons why you feel the information is inappropriate".
All clients were given a copy of the revised client rights. all clients signed their copy in the client record and going forward. the client rights document will be signed on admission and copy will be given in the client handbook.
clients also sign for their copy.
The program director will complete weekly chart review on new admissions documents to ensure a each client has signed that they have received a copy. The executive director will ensure overall compliance.
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709.34 (a) (2) 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:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a licensing inspection conducted on January 23, 2020, the project failed to develop and implement policies and procedures to respond to the selling or use of illicit drugs on the premises.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
709.34 (a) (2):
Reporting of unusual incidents:
On 2/25/2020 Daystar's executive director developed the policy and procedure on unusual incident reporting to include documentation, reporting, and response to the selling or use of illicit drugs on the premises. These incidents will be reported to DDAP 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.
First attention will be focused on the individual or individuals who were either selling or taking illicit drugs will be addressed in the proper manner to fit the situation. The safety of all involved will be a first priority. Then documentation of the unusual incident will include a timely review of the incident and identification of the causes directly or indirectly responsible for the unusual incident. Implementation of a timely and appropriate corrective action plan, when indicated. Ongoing monitoring of the corrective action plan. The electronic or paper form will be the mechanism used to report, to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The policy and reporting will be implemented by the program director and the executive director will ensure overall compliance.
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709.34 (a) (5) 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:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
During a licensing inspection conducted on January 23, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
709.34 (a) (5):
Reporting of unusual incidents:
On 2/25/2020 Daystar's executive director revised the policy and procedure on unusual incident documentation and reporting to include and respond to an unusual incident of theft, burglary, break-in or similar event at the facility. The event will be reported to the police within State and Federal confidentiality laws. Then documentation and reporting of the unusual incident will include a timely review of the incident and identification of the causes directly or indirectly responsible for the unusual incident. Implementation of a timely and appropriate corrective action plan, when indicated. Ongoing monitoring of the corrective action plan. The electronic or paper form will be the mechanism used to report, to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The program director will ensure compliance to this policy and reporting. The executive director will ensure overall compliance.
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709.34 (a) (7) 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:
(7) Fire or structural damage to the facility.
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Observations
During a licensing inspection conducted on January 23, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving fire or structural damage to the facility.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
709.34 (a) (7)
On 2/25/2020 Daystar's executive director revised the policy and procedure on unusual incident documentation and reporting to include and respond to fire or structural damage to the facility. Evacuation policy would be implemented and clients moved to a safe location if required by the extent of the damage. The evacuation policy includes safe housing for the clients if the facility is unsafe. The safety of all involved will be a first priority. Then documentation of the unusual incident will include a timely review of the incident and identification of the causes directly or indirectly responsible for the unusual incident. Implementation of a timely and appropriate corrective action plan, when indicated. Ongoing monitoring of the corrective action plan. The electronic or paper form will be the mechanism used to report, to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The program director will ensure compliance to this policy and reporting. The executive director will ensure overall compliance.
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709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
During a licensing inspection conducted on January 23,2020, the project's policy and procedure manual did not provide policies and procedures on documenting unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
#: 0351
On 2/25/2020 Daystar's executive director revised the policy and procedure on unusual incident documentation and reporting to include how unusual incidents need to be documented immediately and include a timely review of the incident and identification of the causes directly or indirectly responsible for the unusual incident. Implementation of a timely and appropriate corrective action plan, when indicated. Ongoing monitoring of the corrective action plan. The electronic or paper form will be the mechanism used to report, to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. All documentation will be kept in the unusual incident file in the executive director's office.
The program director will ensure compliance to this policy and reporting. The executive director will ensure overall compliance.
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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
During a licensing inspection conducted on January 23, 2020, the project's policy and procedure manual did not provide a policy and procedure to include the prompt review and identification of the cause directly or indirectly responsible for the unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
#: 0353
709.34 (b) (2):
Reporting of unusual incidents:
On 2/25/2020 Daystar's executive director revised the policy and procedure on unusual incident documentation and reporting to include how unusual incidents need to be documented to include a prompt review of the incident and identification of the causes directly or indirectly responsible for the unusual incident. Implementation of a timely and appropriate corrective action plan, when indicated. Ongoing monitoring of the corrective action plan. The electronic or paper form will be the mechanism used to report, to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The program director will ensure compliance to this policy and reporting. The executive director will ensure overall compliance.
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
During a licensing inspection conducted on January 23, 2020, the project's policy and procedure manual did not provide a policy and procedure to include the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
#: 0355
709.34 (b) (4)
On 2/25/2020 Daystar's executive director revised the policy and procedure on unusual incident documentation and reporting to include how unusual incidents needs to be documented to include a timely review of the incident and identification of the causes directly or indirectly responsible for the unusual incident. Implementation of a timely and appropriate corrective action plan, when indicated. Ongoing monitoring of the corrective action plan. The electronic or paper form will be the mechanism used to report, to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The program director will ensure compliance to this policy and reporting. The executive director will ensure overall compliance.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
During a licensing inspection conducted on January 23, 2020, the project's policy and procedure manual did not provide a policy and procedure to include the ongoing monitoring of the corrective action plan for an unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.34 (b) (5)
On 2/25/2020 Daystar's executive director revised the policy and procedure on unusual incident documentation and reporting to include how unusual incidents needs to be documented to include a timely review of the incident and identification of the causes directly or indirectly responsible for the unusual incident. Implementation of a timely and appropriate corrective action plan, when indicated. Ongoing monitoring of the corrective action plan. The electronic or paper form will be the mechanism used to report, to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The program director will ensure compliance to this policy and reporting. The executive director will ensure overall compliance.
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709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a licensing inspection conducted on January 23, 2020, the project's policy and procedure manual did not provide a policy and procedure to include the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
#: 0358
709.34 (b) (3)
On 2/25/2020 Daystar's executive director revised the policy and procedure on unusual incident documentation and reporting to include how unusual incidents needs to be documented to include a timely review of the incident and identification of the causes directly or indirectly responsible for the unusual incident. Implementation of a timely and appropriate corrective action plan, when indicated. Ongoing monitoring of the corrective action plan. The electronic or paper form will be the mechanism used to report, to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The program director will ensure compliance to this policy of documentation and reporting. The executive director will ensure overall compliance.
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