INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 1, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hope Springs Behavioral Health 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel record reviewed.
Employee # 3 was hired as a counselor on October 25, 2021 and was due to have both the HIV/AIDS training and the TB/STD training no later than October 25, 2022. The 6-hour HIV/AIDS training and the 4-hour TB/STD training were not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure all newly hired staff presents certificates to indicate the required 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training certificate and if they have not had the training, they will have three months to complete the required training. The facility director will ensure the newly hired staff will have access to training sites to meet the requirements.
The facility director will check and follow up with the newly hired staff to ensure they have completed the required training and sent the facility director the training certificate for 6 hours of HIV/AIDS training, in addition to the 4 hours of TB/STD training certificate. The facility director will also collect the satisfaction surveys of the trainings.
The facility director will conduct the follow up six months from the date of newly hired staff.
Employee #3 will have the training needed completed in one month.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to document, and make available to the public, an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors, and principal shareholders.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure the owner(s) of the facility contacts the personnel responsible for web design maintenance to include on the website a disclaimer informing the public how to obtain an annual report that includes, but is not limited to, a statement disclosing the names of officers, directors, and principal shareholders.
The website changes will happen no later than December 9, 2022.
The facility director will check the website to ensure the information is on the website.
The facility director and the owners will meet annually to ensure the most updated information is available to the public upon request. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan, during the intake process, in two of two applicable client records reviewed.
Client # 3 was admitted on October 6, 2022 and was still active at the time of the inspection. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
Client # 5 was admitted on October 5, 2022 and was discharged on October 31, 2022. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will amend the policy and procedure manual to include the following: The preliminary treatment plan will be completed within 30 days of the intake. The comprehensive treatment plan will be completed before the fourth individual session visit with the client
The facility director will make the amendment before 12/9/22
The facility director will spot check the charts on a quarterly basis to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in two of four applicable client records reviewed.
Client # 6 was admitted on August 23, 2021 and was discharged on March 23, 2022. A treatment plan update was completed on November 3, 2021 and another update was due no later than January 3, 2022; however, there was no update completed prior to discharge.
Client # 8 was admitted on September 30, 2021 and was discharged on January 5, 2022. The individual treatment and rehabilitation plan was completed on October 13, 2021 and an update was due no later than December 13, 2021; however, there was no update completed prior to discharge.
This is a repeat citation from the November 18, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will have a training during the next clinical staff meetings to make sure the staff are aware of the program policies and state regulations indicating treatment plan updates need to be completed and signed by the client, counselor, and psychiatrist within two months of the comprehensive treatment plan.
The facility director will spot check the charts on a bimonthly basis to ensure the client records are in compliance.
The staff will be trained by November 17, 2022. |
709.93(a)(11) LICENSURE Client records
709.93. 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, the facility failed to document a complete client record, which is to include follow-up information, in one of three applicable client records reviewed.
Client # 7 was admitted on October 8, 2021 and was discharged on November 24, 2021. There was no follow-up information documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will train the staff on the importance of following up with their clients after discharging for continuity of care and documenting in the client records.
The staff will be trained by November 17, 2022.
The charts will spot check client records quarterly to ensure the records are in compliance. |