INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22 - 23, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SpiritLife, Inc. 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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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The facility failed to ventilate the men's bathroom of the recreation building by exhaust fan or window based on a physical plant inspection conducted with the clinical supervisor on March 23, 2018 at approximately 9:00 AM.The findings were reviewed with facilty staff during the licensing process..
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Plan of Correction
Maintenance Supervisor put in a ventilation system through the ceiling to the outside of the rec center on March 29, 2018. Maintenance Supervisor was educated on the requirements of 705.6 (5) and will ensure all current and future buildings meet licensing requirements. Maintenance supervisor will do checks on the ventilation systems twice yearly to ensure proper ventilation. |
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
The facility failed to document a fire drill during sleep hours at least every 6 months based on a review of fire drill records on March 22, 2018.The client's sleeping hours are from 11 PM - 6:30 AM. Fire drills during sleep hours were only conducted on April 28, 2017 and November 29, 2017.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from March 6 - 7, 2017 licensing inspection.
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Plan of Correction
Maintenance staff were trained on regulations of fire drills and expectations of sleeping hour fire drill requirements. Facility will increase fire drills during sleeping hours to once quarterly to assure that the facility is in compliance with 705.10 (d) (5) regulations. This will be effective 4-2-18 and the Safety Committee will be responsible for scheduling and executing the fire drills on a quarterly basis. Executive Director and Clinical Director will audit the fire drill record twice yearly to ensure the fire drill records are completed and in compliance. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to document a financial audit for the November 1, 2016 - October 31, 2017 fiscal year based on a review of financial statements on March 22, 2018.An independent auditor's report dated February 21, 2018 included the following statement "we did not audit or review the financial statements".The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A financial audit encompassing November 1, 2016 through November 1, 2018 will be completed at the end of current fiscal year 2018 through an independent certified public accountant. Executive Director will be responsible for overseeing the completion of the financial audit and will see that a financial audit is done yearly moving forward. |
709.28 (c) 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.
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Observations
The facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in five of fourteen client records reviewed on March 22 - 23, 2018.The client's name and treatment information were released without the client's written consent in the following records.Client # 5 was admitted on January 9, 2018 and discharged on March 13, 2018. The disclosure occurred by fax to a government agency on January 23, 2018. The disclosure occurred by phone to a dentist on January 16, 2018. In addition, the facility exceeded 4 Pa. Code 255.5 by releasing copies of the drug screen results of client # 5 to the insurance company.Client # 9 was admitted on December 27, 2017. The disclosure occurred by phone to a dentist on March 13, 2018. In addition, the facility confirmed that authorization from the client's insurance company was obtained without written consent of the client.The facility failed to document the purpose of disclosure on the consent to release information in the following records.Client # 1 was admitted on March 18, 2018. A consent to a relative was signed by the client on March 19, 2018.Client # 4 was admitted on February 6, 2018 and released on February 9, 2018. A consent to a relative was signed on February 6, 2018.Client # 13 was admitted on February 27, 2018 and discharged on March 20, 2018. A consent to a government agency was signed by the client on February 27, 2017.The facility failed to document the specific information disclosed on the consent to release information in the following records.Client # 1 was admitted on March 18, 2018. A consent to a relative was signed by the client on March 19, 2018.Client # 13 was admitted on February 27, 2018 and discharged on March 20, 2018. Consents to a relative and probation office were signed by the client on February 27, 2017.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 6 - 7, 2017 licensing inspection.
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Plan of Correction
Spiritlife nursing staff were retrained on how to fill out consents as well as the five points of release in regards to the information Spiritlife employees are allowed to disclose to authorized facilities or individuals. Nursing Supervisor will continue to monitor the information released from the nursing department on a weekly basis.
Nursing Supervisor created a letter to confirm date of intake and continued investment in treatment for Vivatrol inquiries by insurance companies effective 3-23-18 and stopped releasing urine drug screens effective 3-22-18. Nursing Supervisor will continue to monitor the information released from the nursing department on a weekly basis.
Clinical Supervisor will retrain clinical staff on confidentiality and release of information on 4-5-18. Clinicians will be educated on how to properly fill out a release of information and the five points of release as well as obtaining consent prior to the release of information. Clinical Supervisor will follow up with clinicians in clinical supervision on a bi-monthly basis to ensure that protocol for confidentiality is followed.
Counselor Aide Supervisor will retrain Counselor Aides on Confidentiality by educating them on the 5 points of release, how and where to check for releases, and what can be released via phone to individuals and other organizations in the event a Counselor Aide is in a position to handle such a call. This training will occur in the monthly CA meeting schedule on 4-16-18 and 4-17-18. Counselor Aide Supervisor will monitor Counselor Aides regularly to ensure compliance with confidentiality and releases.
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