INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dreamlife Recovery LLC 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, a dumpster located outside the kitchen area was not covered to prevent penetration of insects and rodents and had trash bags that were overflowing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/29/21 the Head Chef closed the open dumpster outside of the kitchen area.
On 10/4/21 the QA Coordinator, Facilities Manager and Head Chef collaborated to discuss why the deficiency occurred and how to prevent it from recurring. As a result from the discussion, the following prevention methods have been put into effect as of 10/4/21: 1) The kitchen and maintenance staff have been re-trained on the requirement to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. 2) The Facilities Manager has added this requirement as a standing agenda item on the Monthly QA Facilities Site Inspections to allow for direct observation of compliance with 705.2 (4). In an instance of non-compliance observed, a corrective action plan must be submitted to the Project Director within 48 hours. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The facility video camera system is located within the group counseling areas.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/5/21 the Facilities Manager removed all video cameras from the group counseling areas.
On 10/7/21 the Facilities Manager and QA Coordinator collaborated to update Policy #CL-1:008 to include that all individual and group counseling rooms must be free from any video and/or audio recording devices to ensure privacy and that counseling sessions cannot be seen or heard outside the counseling rooms. All pertinent staff were trained on the revised policy via team meetings.
To prevent the deficiency from recurring, the Facilities Manager has added this requirement as a standing agenda item on the Monthly QA Facilities Site Inspections template to allow for direct observation of compliance with 705.4(3). In an instance of non-compliance observed, a corrective action plan must be submitted to the Project Director within 48 hours.
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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
Based on a review of the project fiscal management, the facility failed to 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 for the fiscal year 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/14/21 the Project Director collaborated with the financial department and the independent certified public accountant to correct the deficiency and perform the 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 for the fiscal year 2020.
On 10/15/21 the QA Coordinator and Project Director collaborated to discuss methods to prevent the deficiency from recurring. As a result, a review of the Annual Financial Audit has been added as an annual standing agenda item for each Quarter 1 QA Committee meeting. During the Q1 review, the Project Coordinator will ensure the Annual Financial Audit has begun and will be completed no later than 6 months from the end of the preceding fiscal year. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on one of six personnel records reviewed, the facility failed to an annual written individual performance evaluation that documents being reviewed and signed by the employee in personnel record # 5.
Employee # 5 was hired as a counselor on October 14, 2019 and was still in this position at the time of the inspection. An annual performance evaluation for employee # 5 did not provide a signature of the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/7/21 The annual performance evaluation for employee #5 was corrected to include the employee's signature. The Project Director provided training to all department supervisors by way of team meetings, specifying that all performance evaluations must include the employee's signature and turned into HR dually signed for placement into the employee's HR file.
As a prevention method, the HR Coordinator has added in the review of performance evaluations, specifically that they are signed by both the employee and supervisor, to the monthly Employee File Audit Checklist. Results from the monthly audit are reported to the QA Committee by the HR Coordinator. In an instance of non-compliance observed, a corrective action plan must be submitted to the Project Director within 48 hours. |