INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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(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 employee #3 received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe. Employee #3 was hired as counselor on 10/17/16 and was due to have HIV/AIDS training and TB/STD training no later than 10/17/17; however, the HIV/AIDS training was completed on 12/5/17 and the TB/STD training was completed on 12/4/17.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with employee number #3 on 12/18/17 to discuss the importance of training timeframes. End of month staff meetings will entail all staffing requirements and training plans for the upcoming calendar year. Facility Director will implement quarterly personnel trainings to ensure compliance. All new staff will be required to complete their trainings within the calendar year of employment. Any new employee will be part of the quarterly review. If an employee does not meet their required training responsibilities they will written up and given two weeks to complete their training requirements. Facility Director will monitor all trainings via staff meetings, individual meetings, and random checks throughout the training year. |
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 the review of the fire drill logs for December 2016 through November 2017, the facility failed to document whether the fire alarm or smoke detector was operative during each fire drill for the time period reviewed.
These findings were reviewed with facility staff during the licensing.
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Plan of Correction
Facility Director will update the current form to include whether the fire alarm or smoke detector is operative during each fire drill. Moving forward the Facility Director will check the lights on the device to ensure of its function on every fire drill conducted. The staff will be informed of this change at the end of month staff meeting. |
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 the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 3 client records. Additionally, 3 client records reviewed had consent to release forms that were missing required elements.
Client #2 was admitted on 11/10/17 and was an active client at the time of the inspection. There was a consent to release information form signed and dated by the client on 11/10/17 to the funding source; however, it expired on 11/10/17. There was no updated consent to release to the funding source documented at the time of the inspection.
Client #3 was admitted on 11/14/17 and was an active client at the time of the inspection. There was a consent to release information form signed and dated by the client on 11/14/17 to the funding source; however, it expired on 11/14/17. There was no updated consent to release to the funding source documented at the time of the inspection.
Client #4 was admitted on 5/30/17 and was discharged on 11/10/17. There was a consent to release information form signed and dated by the client on 6/29/17 to an individual; however, it did not include the specific items to be disclosed.
Client #6 was admitted on 10/12/17 and was discharged on 10/18/17. There was documentation that the facility spoke with a family member on 10/19/17; however, the two consent to release forms for that family member were signed and dated by the client on 10/12/17 with incorrect expiration dates of 4/12/17 and there was no updated consent to release to the family member documented at the time of the inspection. Additionally, one of the consent forms was missing the specific items to be disclosed and the purpose for the disclosure.
Client #7 was admitted on 3/21/17 and was discharged on 7/18/17. There was a consent to release information form signed and dated by the client on 3/21/17 to family members; however, the form did not include the purpose for disclosure. Additionally, there was a consent to release information form signed and dated by the client on 12/8/17 to an external individual; however, the form was missing the specific items to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28(c)
Facility Director will make sure Client #2 updates the consent to release information to the funding source.
Facility Director will make sure Client#3 updates the consent to release information to the funding source.
Staff will be informed how to properly fill out informed consents at the end of month staff meeting.
Moving forward the Facility Director will check client documents two weeks after intake to ensure compliance to the regulation.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of client records on December 14, 2017, it was discovered that the facility failed to notify the Department within 3 days following an unusual incident, which required police presence on-site, that occurred on October 18, 2017.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
709.34(c)
Moving forward the Facility Director will utilize the Unusual Incident Reporting Form NON-NTP provided by the Department of Drug and Alcohol Program to report any incidents within 3 days of occurrence and keep a record of the forms. The Facility Director will ensure the proper form is completed in the event of an incident that meets the reporting requirement. The staff will be informed of the change and trained regarding completing the form at the end of the month staff meeting. The incident that occurred on October 18, 2017 will be reported to the department by 12/26/17. |