INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 17-18, 2016 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The Staffing Requirements Facility Summary Report submitted by the facility was incomplete and inaccurate. The time allotted for the onsite portion of the inspection did not allow for a thorough review of a completed Staffing Requirements Facility Summary Report, and related staffing materials, while onsite. This matter was reviewed with facility staff during the licensing process.
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Plan of Correction
The "Staffing Requirement
Facility Summary Report" will be completed in its entirety prior to the next BDAP Survey by the Clinical Director. Facility will be in full compliance prior to next inspection.
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of personnel records, the project director failed to develop a comprehensive staff development program for agency personnel that included an assessment of staff training needs and an overall plan for addressing these needs. The findings include: Personnel records were reviewed during the licensing renewal inspection on February 17-18, 2016. The project director failed to provide documentation of an assessment of staff training needs and an overall plan for addressing these needs. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director has created a new hire employee check list and will complete a training assessment on all new employees within 30 days. Ongoing training assessments will be completed for each employee annually starting from the date of hire. Clinical Director along with Administrative Assistant (AA) will conduct Quarterly reviews of HR files to ensure compliance.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of individual training plans in two of eight personnel records reviewed.The findings include:Eight personnel records requiring documentation of individual training plans were reviewed during the renewal inspection on February 17-18, 2016. The facility failed to provide documentation of individual training plans for the current training year in personnel records # 1 and 2. Employee # 1 is the project director and has been in this position since 1/1/15. The facility failed to provide documentation of an individual training plan for this employee, as of February 18, 2016. Employee # 2 is the facility director and has been in this position since 1/1/15. The facility failed to provide documentation of an individual training plan for this employee, as of February 18, 2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 3/28/2016 Individual training plans have been completed on Employee #1 Project Director, Employee #2 Facility Director, and all current Staff. Moving forward, at completion of new hire orientation, (one week after hire) the Department Supervisor will meet with their new employees to assess training needs. Clinical Director will ensure that individual training plan is completed within 30 days and annually thereafter. Goal of 100% compliance.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant, the facility failed to provide documentation that cold food was stored at or below a temperature of 40 degrees Fahrenheit. The facility also failed to ensure that frozen food was kept at or below a temperature of 0 degrees Fahrenheit. The findings include:A physical plant inspection was conducted on February 18, 2016. During the inspection of the kitchen area, it was observed that a refrigerator did not contain a thermometer. The facility also failed to maintain a temperature log for this refrigerator. The facility was unable to verify that food in this refrigerator was kept at or below a temperature of 40 degrees Fahrenheit. In addition, it was observed that a freezer showed the temperature to be at 16 degrees Fahrenheit. The temperature log provided for this freezer indicated temperature readings for the months of October, February, and November. A review of this log determined the facility failed to consistently store frozen food at or below a temperature of 0 degrees Fahrenheit. The log also indicates that the facility did not check the temperature daily. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/18/2016 a new thermostat was installed in the observed refrigerator.
Kitchen Supervisor will assure daily logs for both the refrigerators and freezers are logged on daily log sheet to ensure that all refrigerator temperatures are kept below 40 F and all frozen foods are kept at or below a temperature of 0 degrees Fahrenheit. Clinical Director will review temperature logs monthly to assure compliance. Goal of 100% compliance.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of fire extinguishers upon employment in six of eight personnel records reviewed.The findings include:Eight personnel records requiring the documentation of fire extinguisher training were reviewed during the renewal inspection on February 17-18, 2016. The facility failed to document the completion of fire extinguisher training upon employment in personnel records # 3, 4, 5, 6, 7, and 8. Employee # 3 was hired on 9/28/15 as a clinical supervisor. There was no documentation that the employee completed the fire extinguisher training as of the time of the review. Employee # 4 was hired on 11/30/15 as a counselor. There was no documentation that the employee completed the fire extinguisher training as of the time of the review. Employee # 5 was hired on 12/1/15 as a counselor. There was no documentation that the employee completed the fire extinguisher training as of the time of the review. Employee # 6 was hired on 10/5/15 as a counselor. There was no documentation that the employee completed the fire extinguisher training as of the time of the review. Employee # 7 was hired on 1/26/15 as a counselor. There was no documentation that the employee completed the fire extinguisher training as of the time of the review. Employee # 8 was hired on 12/13/15 as a counselor. There was no documentation that the employee completed the fire extinguisher training as of the time of the review. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Assistant/designee and Training Coordinator shall ensure that all new hires receive "fire extinguisher" training within seven days of employment. The Administrative Assistant/designee and Training Coordinator shall meet on a weekly basis to ensure and coordinate the timely occurrence of trainings.
A certificate of completed "fire extinguisher" training shall be placed in the individual's training file.
The Clinical Director will meet with AA to review files and provide oversight to insure 100% compliance.
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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, the facility failed to conduct unannounced fire drills at least once per month as required by regulation.The findings include:The fire drill record was reviewed during the renewal inspection on February 17-18, 2016. There was no documentation of unannounced fire drills for the time period of 7/7/15- 2/18/16. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Campus Supervisor will schedule the date and conduct a fire drill at the beginning of each month and review with the Executive Director. Fire Drill dates will be documented on the fire drill log to have visibility and knowledge of time, date, and outcome. Executive Director will review logs to assure compliance. Effective 4/1/2016. Goal 100% compliance. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, the facility failed to ensure that hard copy client records were secured within locked storage containers. The findings include: A physical plant inspection was conducted on February 18, 2016. In the upper level nurse's station, hard copy records of active clients were observed to be stored in an unlocked file folder cart. The door of this cart was observed to be open and the client records were exposed. The facility confirmed that the cart remains unlocked and open. Access to the nurse's station was not restricted by a locked door. The findings were reviewed with staff during the licensing inspection.
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Plan of Correction
The files in the nursing station have been locked in appropriate file cabinets. The Registered Nurse on shift will have possession of the file cabinet keys. The RN on staff will assure that file cabinets are locked. To ensure this deficiency does not occur again, the Clinical Director has reviewed client record storage protocol with all staff. The Clinical Director will be responsible to monitor the storage of all client records. |
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 records.
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Observations
Based on a review of client records, the facility failed to consistently document verification that the client was offered a copy of the consent to release information form upon signing in three of three records reviewed. The findings included:Three client records were reviewed on February 18, 2016. All client records were reviewed for informed consent forms. The facility failed to document verification that the client was offered a copy of the consent in client records # 1, 2, and 3. Client # 1 was admitted into treatment on 1/17/16 and was still active at the time of the inspection. The facility failed to document verification that the client was offered a copy of the nine consent to release information forms, which were signed and dated by the client, on 1/17/16, 1/28/16, 2/2/16, and 2/15/16. Client # 2 was admitted into treatment on 1/19/16 and was discharged on 2/17/16. The facility failed to document verification that the client was offered a copy of the consent on two consent to release information forms, which were signed and dated by the client on 1/19/16. Client # 3 was admitted into treatment on 1/2/16 and was discharged from the facility on 1/25/16. The facility failed to document verification that the client was offered a copy of the consent on two consent to release information forms, which were signed and dated by the client on 1/2/16 and 1/5/16. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will complete an inservice with staff to review the policy and procedure for proper completion of the consent to release information. Clinical Director will meet individually with staff responsible for client charts #1,2 and 3 to correct insufficient documentation on consent form. Consent forms will be correctly completed to reflect clients being offered a copy. This documentation will be reviewed in monthly chart audits that are conducted by the Clinical Director. Goal 100% compliance. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project to include the reason for termination in one of three client records reviewed. The findings include:One client record requiring written notification to the client of the facility's decision to involuntarily terminate the client's treatment was reviewed on February 18, 2016. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client record # 3. Client # 3 was admitted into treatment on 1/2/16 and was involuntarily terminated from the facility on 1/25/16. Written notification to the client of the facility's decision to involuntarily terminate the client's treatment was not documented in the client's record.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will inform patients of the decision of an involuntary discharge. Staff will ask patient to sign termination form which will outline the purpose of termination from treatment. If patient refuses to acknowledge this or sign the form,staff will write on communication sheet whether they gave client a copy of the form and whether client refused to sign the form. Goal 100% compliance. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history in one of one client records reviewed for short-term detoxification treatment services. The findings include:Three client records were reviewed on February 18, 2016. One of the three client records was reviewed for short-term detoxification treatment services. This client record, specifically client # 3, required documentation of a personal history, as part of the intake procedures. The facility failed to document a personal history in client record # 3. Client # 3 was admitted into short-term detoxification treatment on 1/2/16 and was discharged from detoxification treatment on 1/8/16. The facility failed to document the completion of a personal history, as part of the intake procedures, in the client's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will conduct training with clinical staff on psycho-social interviewing and documentation; specifically focusing on gathering detailed answers that will give the reader a better understanding of the patient's personal history to include family, childhood, and any major or significant life events. Clinical Director will audit records weekly for compliance. Goal 100% compliance. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in one of one client records reviewed for short-term detoxification treatment services. The findings include:Three client records were reviewed on February 18, 2016. One of the three client records was reviewed for short-term detoxification treatment services. This client record, specifically client # 3, required documentation of a psychosocial evaluation, as part of the intake procedures. The facility failed to document a psychosocial evaluation in client record # 3. Client # 3 was admitted into short-term detoxification treatment on 1/2/16 and was discharged from detoxification treatment on 1/8/16. The facility failed to document the completion of a psychosocial evaluation, as part of the intake procedures, in the client's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will facilitate training with clinical staff on psycho-social interviewing and documentation; focusing on proper documentation of each client's assets and strengths and how to identify the client's coping mechanisms from the staff's perspective. Clinical Director will audit records weekly for compliance. Goal 100% compliance.
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709.63(a) LICENSURE Client record
709.63. 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:
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Observations
Based on a review of client records, the facility failed to ensure that a complete record was documented in one of one client records reviewed for short-term detoxification treatment services. The findings include:Three client records were reviewed on February 18, 2016. One of the three client records was reviewed for short-term detoxification treatment services. This client record, specifically client # 3, required documentation of a complete client record. The facility failed to document a complete client record in client record # 3. Client # 3 was admitted into short-term detoxification treatment on 1/2/16 and was discharged from detoxification treatment on 1/8/16. A record of service was not documented in the client's record. Progress notes in the client's record indicated that the client attended group therapy sessions on 1/5/16 and 1/6/16. Additionally, progress notes in the client's record indicated that the client attended individual therapy sessions on 1/4/16, 1/5/16, 1/6/16, and 1/8/16. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will hold in-service with clinical staff reminding them of the required documentation
specifically the record of service and progress notes. Clinical Director will conduct bi-weekly chart audits to monitor compliance. Goal 100% compliance. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history in two of three client records reviewed. The findings include:Three client records requiring documentation of a personal history, as part of the intake procedures, were reviewed on February 18, 2016. The facility failed to document a personal history in client records # 2 and 3. Client # 2 was admitted into treatment on 1/19/16 and was discharged on 2/17/16. The facility failed to document the completion of a personal history, as part of the intake procedures, in the client's record. Client # 3 was admitted into inpatient rehabilitation treatment on 1/8/16 and was discharged on 1/25/16. The facility failed to document the completion of a personal history, as part of the intake procedures, in the client's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will facilitate training with pertinent staff on psycho-social interviewing and documentation; specifically focusing on gathering detailed answers that will give the reader a better understanding of the patient's personal history to include family, childhood, and any major or significant life events. Clinical Director will audit records bi-weekly
to monitor compliance. Goal 100% compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation, as part of the intake procedures, in two of three client records reviewed.The findings include:Three client records requiring documentation of a psychosocial evaluation were reviewed on February 18, 2016. The facility failed to document a psychosocial evaluation in client records # 2 and 3. Client # 2 was admitted into treatment on 1/19/16 and was discharged on 2/17/16. The facility failed to document a psychosocial evaluation in the client's record. Client # 3 was admitted into inpatient rehabilitation treatment on 1/8/16 and was discharged on 1/25/16. The facility failed to document a psychosocial evaluation in the client's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will facilitate training with clinical staff on psycho-social interviewing and documentation; specifically focusing on gathering detailed answers that will give the reader a better understanding of the patient's personal history to include family, childhood, and any major or significant life events. Clinical Director will audit records bi-weekly to monitor compliance. Goal 100% compliance. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that included short and long-term goals for treatment, as formulated by both staff and the client, in one of three client records reviewed. The findings include: Three client records requiring documentation of an individual treatment and rehabilitation plan were reviewed on February 18, 2016. The facility failed to document an individual treatment and rehabilitation plan that included short and long-term goals for treatment in client record # 1. Client # 1 was admitted into treatment on 1/17/16 and was still active at the time of the inspection. The individual treatment and rehabilitation plan documented in the client's record was completed on 1/19/16. This treatment plan did not document short and long-term goals for treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will meet with all counselors at the facility on documenting both short term and long term goals on treatment plans. The Clinical Director will assure compliance with this standard through monthly chart audits and regularly scheduled supervision with the counselors. Goal 100% compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and/or frequency of treatment services on the individual treatment and rehabilitation plan in three of three client records reviewed. The findings include:Three client records requiring documentation of the type and frequency of treatment services on the individual treatment and rehabilitation plans were reviewed on February 18, 2016. The individual treatment and rehabilitation plans documented in client records # 1, 2, and 3 did not specify the type and/or frequency of treatment services. Client # 1 was admitted into treatment on 1/17/16 and was still an active client at the time of the inspection. The client's individual treatment and rehabilitation plan, dated 1/19/16, did not specify the type and frequency of treatment services. Client # 2 was admitted into treatment on 1/19/16 and was discharged on 2/17/16. The client's individual treatment and rehabilitation plan, dated 1/20/16, did not specify the frequency of treatment services. Client # 3 was admitted into inpatient rehabilitation treatment on 1/8/16 and was discharged on 1/25/16. The client's individual treatment and rehabilitation plan, dated 1/8/16, did not specify the frequency of treatment services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be trained to complete treatment plans to ensure that type of services and frequency of services are documented on a consistent basis. Clinical Director will conduct bi-weekly chart audits to monitor process. Goal 100% compliance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in one of three client records reviewed. The findings include:Three client records were reviewed on February 18, 2016. The facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in client record # 2. Client # 2 was admitted into treatment on 1/19/16 and was discharged on 2/17/16. The client's individual treatment and rehabilitation plan, dated 1/20/16, indicated that the client was to receive individual counseling sessions. The client's record indicated that the client did not receive any individual counseling sessions while in treatment. Individual counseling sessions were not documented on progress notes or on a record of service for the client. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling services will be provided on a regular scheduled basis as indicated by the client's phase of treatment within the program. The Clinical Director will address this issue with clinical staff at a weekly clinical staff meeting. A review of all charts and activity log will be done by clinical staff with supervision by the clinical supervisor to make sure treatment plan interventions from the time of the incident are congruent with documentation. The Clinical Director
will conduct bi-weekly chart audits to assure compliance. Goal 100% compliance. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on the review of client records, the facility failed to ensure that a complete record on an individual which includes information relative to the client's involvement with the project was documented in three of three client records reviewed.The findings include:Three client records were reviewed for documentation of a complete client record on February 18, 2016. The facility failed to document a complete record in client records # 1, 2, and 3. Client # 1 was admitted into treatment on 1/17/16 and was still active at the time of the inspection. Progress notes documented in the client's record indicated that the client attended individual counseling sessions on the following dates: 1/26/16, 1/31/16, 2/2/16, 2/4/16, 2/7/16, 2/9/16, 2/14/16, and 2/16/16. These individual counseling sessions were not documented on the client's record of service. Additionally, progress notes for individual counseling sessions attended by the client on 2/4/16 and 2/9/16 did not document the name of the counselor. Client # 2 was admitted into treatment on 1/19/16 and was discharged on 2/17/16. A record of service for the client was not documented in the client's record . Progress notes documented in the client's record indicated that the client attended group therapy sessions on the following dates: 1/21/16, 1/22/16, 1/25/16, 1/26/16, 1/27/16, 1/28/16, 1/29/16, 2/1/16, 2/2/16, 2/3/16, 2/4/16, and 2/5/16. Additionally, a progress note documented in the client's record indicated that the client attended a family therapy session on 2/14/16. Client # 3 was admitted into inpatient rehabilitation treatment on 1/8/16 and was discharged on 1/25/16. Progress notes documented in the client's record indicated that the client attended group therapy sessions on the following dates: 1/11/16, 1/13/16, 1/15/16, 1/18/16, 1/19/16, and 1/25/16. These group therapy sessions were not documented on the client's record of service. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors were informed by the Clinical Director that all clinical files must contain record of treatment activities. The clinical supervisor will review all clinical files bi-weekly to ensure that all client participation activities are noted in the chart along with the date, time and initials. Goal 100% compliance. |