INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hopebridge DT 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure the qualification project director and facility director met qualifications in one of one applicable file reviewed. Employee #1 was hired as the project director and facility director on February 15, 2024. There was no documentation in the record of a qualifying college degree and/or transcripts and a job resume; therefore, Department staff was unable to determine if the employee met both the educational and experiential qualifications for the positions.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
To correct this deficiency, the facility will obtain and file the necessary documentation for Employee #1, including a qualifying college degree, transcripts, and job resume, by August 15, 2024. The Human Resources Manager is responsible for this action.
To ensure this deficiency does not recur, the facility will implement a checklist for new hires that includes verification of educational and experiential qualifications before the employment start date, with the Human Resources Manager reviewing all new hire files for compliance. Additionally, the facility will conduct quarterly audits of personnel files, overseen by the Compliance Officer, with the first audit completed by November 15, 2024.
Human Resources staff will receive training on maintaining complete and accurate personnel files by September 1, 2024, conducted by the Training Coordinator. The facility will ensure all personnel files are updated with the necessary documentation and establish a system for regular review, with the Human Resources Manager responsible for this task. |
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 and the Staffing Requirements Facility Summary Report, the facility failed to develop a written individual training plan for each employee, which shall be completed with input from both the employee and the supervisor in two of two personnel records reviewed.Employee #1 was hired as the project director and facility director on February 15, 2024. There was no current training plan documented at the time of the inspection.Employee #2 was hired as a counselor on June 1, 2024. There was no current training plan documented at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct this deficiency, the facility will develop written individual training plans for both employees by August 15, 2024, with input from the employees and their supervisors. The Human Resources Manager will oversee this process. To prevent recurrence, the facility will create a standardized template for individual training plans by August 10, 2024, establish a policy requiring annual training plan development within 30 days of hire and annually thereafter by August 15, 2024, and implement a tracking system to monitor due dates for training plan updates by August 20, 2024.
Quarterly audits of personnel files will be conducted, with the first audit completed by November 15, 2024, overseen by the Compliance Officer. Supervisors will be trained on the importance and process of creating individual training plans by September 1, 2024, conducted by the Training Coordinator.
The Compliance Officer will monitor the effectiveness of these measures through quarterly audits and report findings to the Facility Director. All corrective actions will be fully implemented by September 1, 2024, with ongoing monitoring and annual reviews thereafter. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher 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 that staff were trained in the use of fire extinguishers upon staff employment in one of two personnel records reviewed.Employee #1 was hired as the project director/facility director on February 15, 2024. There was no documentation of training in the use of fire extinguishers in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct this deficiency, the facility will provide and document fire extinguisher training for Employee #1 by August 15, 2024, conducted by the Training Coordinator.
To prevent recurrence, the Human Resources Manager will implement a new hire checklist including mandatory fire extinguisher training by August 20, 2024. A comprehensive review of all current employee files will be completed by September 1, 2024, to ensure fire extinguisher training is documented for all staff.
The Facility Director will establish a policy requiring fire extinguisher training within the first week of employment for all new hires by August 31, 2024. Quarterly audits of personnel files will be conducted, with the first audit completed by November 15, 2024, overseen by the Compliance Officer.
Annual refresher training on fire extinguisher use will be implemented for all staff, with the first session completed by October 1, 2024. The Training Coordinator will organize and document these sessions. All corrective actions will be fully implemented by September 1, 2024, with ongoing monitoring and annual reviews thereafter.
The Facility Director will oversee the implementation and effectiveness of all corrective measures. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of two personnel records reviewed.Employee #1 was hired as the project director/facility director on February 15, 2024. There was no documentation of training on the assignment of tasks during emergencies at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has developed a comprehensive Plan of Correction (POC) to address the citation under regulation 705.28 (d) (3) regarding fire safety and emergency task training. To correct the identified deficiency related to Employee #1's training documentation, the facility will provide comprehensive emergency task training by August 12, 2024, and ensure this training is documented in the personnel file.
To prevent recurrence, the facility will implement a standardized emergency task training program for all staff, create a new hire checklist for timely training, conduct quarterly refresher sessions, and perform monthly audits of personnel files. The Human Resources Manager will oversee these corrective actions and ensure continued compliance. The full implementation of the new training program will be completed by September 1, 2024.
This timeframe is realistic, allowing for immediate correction while ensuring comprehensive training measures are in place. The facility acknowledges the deficiency identified during the licensing process and is committed to addressing all aspects of the issue. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's January 2024 through June 2024 fire drill logs, the facility failed to maintain a complete, written fire drill log, which is to include all the regulatory requirements.Every fire drill reviewed was missing documentation of whether the fire alarm or smoke detector was operative during the drill. Additionally, the fire drill logs for March 2024 through June 2024 were missing the times that the fire drill was conducted. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct the identified deficiencies in the fire drill logs from January 2024 through June 2024, the facility will add the missing information regarding the operability of the fire alarm and smoke detector, as well as the times of the drills, by August 15, 2024.
To prevent recurrence, the facility will implement a new fire drill log template that includes all required elements, establish a policy for the Safety Officer to review and sign off on logs, conduct monthly audits, and provide training to staff on proper documentation procedures. The Safety Officer will oversee the implementation of these corrective actions, ensuring compliance by September 1, 2024.
This timeframe allows for immediate correction while ensuring comprehensive measures are in place. The facility acknowledges the deficiencies identified during the licensing process and is committed to addressing all aspects of the issue. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's February 2024 through July 2024 fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill. The documented method of announcing the fire drills was by "Phone" during every fire drill log reviewed, which indicated that the fire alarm or smoke detector was not set off during the fire drills.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct this deficiency and ensure compliance with regulation 705.28, the facility will provide and document comprehensive emergency task assignment training for Employee #1 by August 15, 2024, conducted by the Training Coordinator.
This training will include a practical component where the fire alarm will be set off during the training to familiarize staff with the emergency response procedures.
To prevent recurrence, the Human Resources Manager will implement a new hire onboarding checklist that includes mandatory emergency task assignment training by August 20, 2024.
The Facility Director will establish a policy requiring emergency task assignment training to be completed and documented within the first week of employment for all new hires, effective August 31, 2024. The Training Coordinator will develop a comprehensive emergency response training program that covers all shifts and roles by September 1, 2024. Additionally, the Facility Director will create an emergency response plan outlining specific tasks for all staff across all shifts by September 15, 2024.
A thorough review of all current employee files will be conducted by the Human Resources Manager by September 1, 2024, to ensure emergency task assignment training is documented for all staff across all shifts. The Compliance Officer will oversee quarterly audits of personnel files to ensure ongoing compliance, with the first audit completed by November 15, 2024. Annual refresher training on emergency task assignments will be implemented for all staff, with the first session completed by October 1, 2024, organized and documented by the Training Coordinator.
All corrective actions will be fully implemented by September 15, 2024, with ongoing monitoring and annual reviews thereafter. The Facility Director will oversee the implementation and effectiveness of all corrective measures. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to ensure personnel records included the written verification of qualifying professional credentials in one of two personnel records reviewed.Employee #1 was hired as the project director/facility director on February 15, 2024. There was no documentation of the qualifying professional credentials in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct the identified deficiency in Employee #1's active personnel file, the facility will obtain and document the required written verification of qualifying professional credentials by August 12, 2024.
To prevent recurrence, the facility will implement a standardized hiring checklist that includes verification of professional credentials, conduct quarterly audits of all personnel files, and provide training to HR staff on proper documentation requirements. The Human Resources Manager will be responsible for implementing these corrective actions and ensuring continued compliance.
Full implementation of the new procedures will be completed by September 1, 2024. This timeframe is realistic, allowing for immediate correction while ensuring comprehensive measures are in place. The facility acknowledges the deficiency identified during the licensing process and is committed to addressing all aspects of the issue.
The facility will correct the specific deficiency in Employee #1's file and implement systemic changes to prevent future occurrences for all current and future staff. |
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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in seven of seven client records reviewed. In every client record reviewed, there was documentation of disclosures to the funding sources during the client's treatment episode; however, there were no consent to release information forms, signed by the client, documented in the records prior to any of the disclosures.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility will correct the identified deficiency in all seven active client records by obtaining the necessary consent forms by August 15, 2024. To prevent recurrence, a standardized consent form will be developed, and a new intake procedure will be implemented to ensure signed consent forms are obtained prior to any disclosures.
Monthly audits of client records will be conducted to verify compliance, and all staff will receive training on confidentiality requirements and proper consent procedures. The Clinical Director will oversee the implementation of these corrective actions. Full implementation of the new procedures, including staff training and the first round of audits, will be completed by September 1, 2024.
This timeframe allows for immediate correction while ensuring comprehensive measures are in place. The facility acknowledges the deficiencies identified during the licensing process and is committed to addressing all aspects of the issue. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of seven client records reviewed.Client # 2 was admitted on February 21, 2024 and was still active at the time of the inspection. The release of information form to the client's family was signed and dated by the client on February 21, 2024, but the release form did not include the specific information to be disclosed. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To correct the identified deficiency in Client #2's record, the facility will obtain a new consent form that clearly specifies the information to be disclosed by August 15, 2024.
To prevent recurrence, the facility will revise the consent form template to include a field for specific disclosures, implement a procedure for staff to review consent forms for completeness, conduct monthly audits of client records, and provide training to staff on confidentiality and consent documentation. The Clinical Director will oversee the implementation of these corrective actions, ensuring compliance by September 1, 2024.
This timeframe allows for immediate correction while ensuring comprehensive measures are in place. The facility acknowledges the deficiencies identified during the licensing inspection and is committed to addressing all aspects of the issue. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include case consultation notes, in five of five applicable client records reviewed. Client # 1 was admitted into the program on February 21, 2024 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection. Client # 2 was admitted into the program on February 21, 2024 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection. Client # 3 was admitted into the program on March 7, 2024 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection. Client # 4 was admitted into the program on February 5, 2024 and was discharged June 4, 2024. There were no case consultation notes documented in the record at the time of the inspection. Client # 5 was admitted into the program on February 20, 2024 and was discharged June 4, 2024. There were no case consultation notes documented in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct the identified deficiency in the records of Clients #1, #2, and #3, the facility will conduct case consultations and document the notes in their respective files by August 15, 2024. For Clients #4 and #5, who have been discharged, the facility will document the absence of case consultation notes in their records and implement measures to prevent future occurrences.
To ensure compliance and prevent recurrence, the facility will develop a standardized case consultation note template, implement a policy for weekly case consultations, conduct monthly audits of client records, and provide training to clinical staff on proper documentation practices. The Clinical Supervisor will oversee the implementation of these corrective actions, with full compliance expected by September 1, 2024.
This timeframe allows for immediate correction while ensuring comprehensive measures are in place. The facility acknowledges the deficiencies identified during the licensing process and is committed to addressing all aspects of the issue. |