INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 10, 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 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2021 through December 31, 2021 training year in one of one applicable personnel record reviewed.
Employee # 2 was hired as a counselor on April 7, 2014. The personnel record documented 17.5 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure that any staff who is unable to complete their required 25 clock hours of training due to medical leave has a waiver requesting exemption completed to ensure compliance.
The facility director will audit the staff records on an annual basis in October of the training year to ensure the staff are completing their training requirements prior to the end of the training cycle.
The amendment will be made in the policy and procedure manual by 11/28/22 |
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. |