INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2020 through January 15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to adhere to the project's policy and procedures on collecting feedback on completed trainings. Per the project's policy, every completed training was to have a documented feedback form; however, each employee record reviewed were missing feedback forms for every completed training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility changed the project's policy indicating there will be a discussion in the project's staff meeting to discus recent trainings attended not a feedback form. The facility director will ensure the agenda for the staff meeting will include a discussion of any recent trainings attended by staff to discuss the training and the quality of the training attended. |
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
The facility failed to provide documentation of an individual training plan for the 2019 training year in one of four employee records reviewed.
Employee # 4 was hired as counselor on March 7, 2019. There was no documentation of an individual training plan completed within 30 days of hire for the last training year, which was identified as January 1, 2019 to December 31, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director implemented a training form for the upcoming training year to be completed by the staff annually. All new hires will have the training form added to their orientation packets and be expected to complete the form within 30 days of hire. The policy and forms were introduced to the staff during staff meeting held on 1/21/2020. The facility director will check personnel records annually and within 30 days of a new hire to ensure compliance. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct an unannounced fire drill during the months of March, May, July, September and November 2019. This was based on a review of the January 2019 through December 2019 fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will conduct unannounced fire drills every month to ensure compliance. The facility director announced the correction at the staff meeting held on 1/21/2020. The facility director will audit the fire drill logs quarterly to ensure compliance. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per the financial exception letter on file the project's drug and alcohol services will be tracked utilizing the newly implemented electronic billing and record system to differentiate between drug/alcohol services and others. The tracking report will include services that were billable and services that were received. The facility director will ensure the report is readily available for the following year upon request. Tax returns will also be provided upon request as stipulated in the exception request. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 3 of 10 client records reviewed.
Client # 5 was admitted on August 15, 2019 and was still active at the time of the inspection. There was documentation of the facility contacting a significant other on November 14, 2019; however, there was no consent to release information form to the significant other on file prior to the disclosure.
Client # 6 was admitted on October 22, 2019 and was discharged on December 18, 2019. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file prior to the disclosure of information.
Client # 8 was admitted on April 2, 2019 and was discharged on June 27, 2019. There was documentation of the facility conducting individual and group sessions between April 2, 2019 and April 16, 2019 and subsequently billing the funding source; however, the consent to release information form to the funding source was not completed until April 17, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility director will include the drug and alcohol specific consent to release information in the client intake packet for all clients being admitted. The facility director implemented a policy indicating the client's who names an emergency contact on their intake, the person named needs to have a consent on file in accordance to drug/alcohol regulations. The facility director will check charts on quarterly basis for compliance. The staff was informed of the policy change on 1/21/2020 during a staff meeting. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to include documentation verifying written acknowledgement by clients that they had been informed that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, in 8 of 10 client records reviewed.
Client # 1 was admitted to the outpatient level of care on November 7, 2019 and was active at the time of the inspection.
Client # 2 was admitted to the outpatient level of care on December 4, 2019 and was active at the time of the inspection.
Client # 3 was admitted to the outpatient level of care on November 7, 2019 and was active at the time of the inspection.
Client # 5 was admitted to the outpatient level of care on August 15, 2019 and was active at the time of the inspection.
Client # 6 was admitted to the outpatient level of care on October 22, 2019 and was discharged on December 18, 2019.
Client # 8 was admitted to the outpatient level of care on April 2, 2019 and was discharged on June 27, 2019.
Client # 9 was admitted to the outpatient level of care on July 9, 2018 and was discharged on November 13, 2019.
Client # 10 was admitted to the outpatient level of care on November 25, 2019 and was discharged on January 8, 2020.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The facility director purged the all of the former intake packets that did not include the complete documentation written acknowledgement by clients that they had been informed that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion and replaced with the complete client right forms. The client's charts 1, 2, 5 had the new forms completed by clients. The facility director will audit charts quarterly to ensure compliance. |