INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 06, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
Employee #1 was hired as Project Director on February 10, 2015 and was in that position at the time of the inspection. The facility's training year that was reviewed was from July 1, 2024 through June 30, 2025. Employee # 1's employee record had no documented hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(d)(2) LICENSURE
Annual Training Requirements:
The Project Director, Employee #1, did not have the proper trainings required for training year 7-1-2024 - 6-30-2025.
the Program Director implemented, on 2/20/26, a quarterly training review and reminder system for all staff. this action will ensure all staff members have the appropriate trainings. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the purpose of the disclosure in four out of seven records reviewed.
Client #3 was admitted on August 20, 2025, and discharged on October 09, 2025. An informed and voluntary consent form from the client for the disclosure of information for a family program, signed and dated August 20, 2025, did not include the purpose of disclosure.
Client #5 was admitted on October 10, 2025 and was still active at the time of the inspection. An informed and voluntary consent form from the client for disclosure of information for a sponsor and outside medical facility, signed and dated October 10, 2025 and November 06, 2025, respectfully, did not include the purpose of disclosure.
Client #6 was admitted on September 15, 2025 and was still active at the time of the inspection. An informed and voluntary consent form from the client for disclosure of information for a family member, outside medical facility, and funding source, signed and dated September 15, 2025, did not include the purpose of disclosure.
Client #7 was admitted on August 25, 2025 and was still active at the time of the inspection. An informed and voluntary consent form from the client for disclosure of information for a family program, sponsor, and outside medical facility, signed and dated August 25, 2025, did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c) (3) LICENSURE
Confidentiality:
This deficiency is a result of our EMR. There was a problem in the system that caused the purpose of the release, check boxes to not work. In client records #3, #5, #6 and #7 the boxes to check mark for the purpose of the release did not hold the check mark. As of 2/21/2026. all staff that obtain releases of information are using a different Release until the medical records tech department is able to fix the issue permanently. the clinical supervisor will oversee this process to ensure compliance. |
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.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in four of four applicable records reviewed. The facility's policy and procedure manual states that follow-up will be completed within 7 and 30 days of discharge.
Client #1 was admitted on April 17, 2025 and was discharged on August 22, 2025. The client was due to have a seven day follow-up completed by August 29, 2025; however, one was not completed until September 10, 2025.
Client #2 was admitted on July 24, 2025 and was discharged on May 20, 2025. The client was due to have a seven day follow-up completed by November 27, 2025; however, one was not completed until December 10, 2025.
Client #3 was admitted on August 20, 2025 and was discharged on October 09, 2025. The client was due to have a seven day follow-up completed by October 16, 2025; however, one was not completed until November 05, 2025.
Client #4 was admitted on October 09, 2025 and was discharged on January 15, 2026. The client was due to have a seven day follow-up by January 22, 2026; however, one was not completed until January 30, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.53(a)(11) LICENSURE
Follow-up information:
The follow up policy has been changed, as of 2/20/2026. the change reflects that follow-ups will be completed 30 day after discharge rather that the 7 days in the prior policy. the change in policy allows case management additional time to contact the discharged client. The Executive Director, Fern Wilcox is to ensure overall compliance. |