INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 30, 2013, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met the qualifications for the position in one of one personnel record reviewed.The findings included:One personnel record was reviewed on December 30, 2013. Employee # 1 was hired on November 25, 2013, as a counselor. The documentation noted a verified bachelor's degree in social work from May 2013. The employee did not have a year of required clinical experience documentation. The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
Employee #1 has been moved to assistant counselor status with supervisory oversight by the executive director and certified part time therapist. Executive Director keeps supervisory notes with additional input from certified part time therapist.
Facility is in full compliance |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of current client census information and clinical staff hours, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every ten clients.The findings included:The current client census information and clinical staff hours were reviewed on December 30, 2013. The inpatient nonhospital treatment and rehabilitation project has a waiver for a 10 client to 1 counselor ratio. There is currently one full time counselor at this facility. Upon review of the counselor's credentials, the counselor assistant did not meet the requirements for a caseload without documentation of a supervisor's positive assessment of the counselor assistant's individual skill level.The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
Executive Director provides supervision for employee #1 and has made a positive assessment of the assistant counselor's ability to carry a case load. Positive assessment is included in supervision notes for January 3, 2014.
Facility is in full compliance |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of administrative documentation, the facility failed to document the completion of monthly unannounced fire drills and the required components of the fire drill record.The findings included:A review of the fire drill record was conducted on December 30, 2013. The fire drill record was reviewed from the time period of the previous inspection (January 2013) to current inspection (December 2013). Documentation was missing for a fire drill conducted for the month of April 2013. Additionally, the fire drill record for March 2013 and November 2013 were missing the time it took for evacuation.The findings were reviewed with the Operations Manager and the Facility Director and confirmed.
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Plan of Correction
Executive Director meets with operations manager in the last week of the month for facility review and will add review of the current months fire drill to make sure it has taken place and that the record is filled out completely.
Facility is in full compliance |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in six of seven patient records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in one of seven records reviewed. The findings included:Seven client records were reviewed December 30, 2013. All records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in six client records reviewed, # 1, 2, 3, 4, 5, and 6.A review of client record # 1 revealed information was released to a funding source on December 16, 2013. The client record did not contain a release of information to the funding entity at the time of the review. A review of client record # 2 revealed information was released to a funding source on November 27, 2013. The client record did not contain a release of information to the funding entity at the time of the review.A review of client record # 3 revealed information was released to a funding source on December 5, 2013. The client record did not contain a release of information to the funding entity at the time of the review.A review of client record # 4 revealed information was released to a funding source. The client record did not contain a release of information to the funding entity at the time of the review.A review of client record # 5 revealed information was released to a funding source. The client record did not contain a release of information to the funding entity at the time of the review. Additionally, a consent to release information signed by the client for a funding source on May 28, 2013, did not contain the information to be released.A review of client record # 6 revealed information was released to a funding source on June 3, 2013, and to a transportation referral entity on June 25, 2013. The client record did not contain a release of information for either the funding entity or the transportation referral at the time of the review. Additionally, a consent to release information was documented for a legal entity on June 14, 2013, that included releasing results of urine tests. This information is beyond the scope of 4 Pa. Code, Subsection 255.5(b).
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Plan of Correction
Consent to release information for client record #1 is under the case management tab of client chart on Medical Assistance application form PA 1672 dated December 16, 2013
Consent to release information for client record #2 is under the case management tab of client chart on Medical Assistance application form PA 1672 dated November 25, 2013
Consent to release information for client record #3 is under the case management tab of client chart on Medical Assistance application form PA 1672 dated December 5, 2013
Consent to release information for client record #4 is under the case management tab of client chart on Medical Assistance application form PA 1672 dated September 19, 2013. Consent for another funder is under consent tab for CCBH dated September 13, 2013
Client record #5 contains two consents for funders dated May 28, 2013. Both consents indicate the information to be released. The only other consent for a funder is on MA Application for PA 1672 dated June 4,2013 and is located under the case management tab
Client record #6 contains a consent to release information to a funding source on medical assistance application form PA 1672 dated May 21, 2013. This consent is located under the case management tab.
A consent for medical assistance transportation has been added to the consent tab of client charts.
Legal entities will henceforth be informed that we cannot share the results of urinalysis because it is beyond the scope of 4 Pa. code, subsection 255.5(b) Compliance officer will monitor ongoing compliance. |