INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 18, 2021 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:
|
Plan of Correction
|
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.
|
Observations
Based on review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies in two of seven personnel records reviewed.
Employee # 2 was hired as a counselor on February 21, 2021. The emergency preparedness training was not provided to the employee as of the date of inspection.
Employee # 3 was hired as a counselor on February 21, 2021. The emergency preparedness training was not provided to the employee as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director will ensure that all personnel are trained to perform assigned tasks during emergencies.
The facility director will ensure the personnel trained will sign off indicating the date of the training as part of their orientation.
Facility director will audit personnel records to ensure compliance 14 days after new hire |
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.
|
Observations
Based on a review of the facility's February 2021 through October 2021 fire drill logs, the facility failed to identify, on their drill log, whether the fire alarm or smoke detector was operative for every fire drill conducted during the reviewed period.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Facility director will amend the fire drill logs to include fire alarm and smoke detectors are in operating order.
Facility director will audit the fire drill logs quarterly to ensure the program is in compliance. |
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.
|
Observations
Based on a review of the facility's February 2021 through October 2021 fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill conducted during the reviewed period.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Facility director will ensure the smoke detector or fire alarm will be set off during each of the fire drills.
The facility director will write a letter to request a waiver to have the facility not be required to set off the fire alarm due to other occupants in the building not part of the facility.
Facility director will conduct the fire drills at the facility on a monthly basis. |
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.
|
Observations
Based on a review of client records, the facility failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of seven client records reviewed.
Client # 4 was admitted on March 3, 2021 and was discharged on June 18, 2021. A release of information form to a funding source was signed and dated by the client on March 3, 2021 that allowed for the release of assessment and evaluations, entire mental health record, psychosocial history, and discharge summary, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 6 was admitted on May 24, 2021 and was discharged on August 25, 2021. A release of information form to a funding source was signed and dated by the client on May 24, 2021 that allowed for the release of assessment and evaluations, entire mental health record, psychosocial history, and discharge summary, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 7 was admitted on August 12, 2021 and was discharged on November 3, 2021. A release of information form to a funding source was signed and dated by the client on August 12, 2021 that allowed for the release of assessment and evaluations and entire mental health record, all of which exceeded the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will ensure all of the releases in the clinical records for clients in the drug and alcohol program meet the requirements for PA code 255.5.
Facility director will spot check charts on quarterly basis to make sure the client records are in compliance to PA code 255.5. The facility director will have a training at one of the weekly staff meetings by December 31, 2021. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
|
Observations
Based on a review of client records, the facility failed to document the dated signature of a witness on release of information forms in one of seven client records reviewed.
Client # 4 was admitted on March 3, 2021 and was discharged on June 18, 2021. Release of information forms to a funding source and a physician were signed and dated by the client on March 3, 2021; however, both forms did not include the dated signature of a witness.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will ensure to remove double sided documents to eliminate the potential of having documents not in compliance in the client records.
Facility director will implement spot checks on quarterly basis to ensure the client records are in compliance. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which a consent to release information form would expire in one of seven client records reviewed.
Client # 6 was admitted on May 24, 2021 and was discharged on August 25, 2021. A release of information form to a funding source was signed and dated by the client on May 24, 2021, and the form did not include a date, event, or condition upon which the consent would expire.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will ensure all of the releases in the clinical records for clients in the drug and alcohol program meet the requirements for PA code 255.5.
Facility director will spot check charts on quarterly basis to make sure the client records are in compliance to PA code 255.5. The facility director will have a training at one of the weekly staff meetings by December 31, 2021.
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of five applicable client records reviewed.
Client # 1 was admitted on August 23, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on August 31, 2021 and the first update was due no later than October 30, 2021; however, the update was completed on November 3, 2021.
Client # 7 was admitted on August 12, 2021 and was discharged on November 3, 2021. The comprehensive treatment plan was completed on August 24, 2021 and the first update was due no later than October 23, 2021; however, the update was completed on October 26, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will have a training during one of the staff meetings to make sure the employees are aware of the program policies indicating comprehensive treatment plans need to be completed and signed by the client, counselor, psychiatrist, and facility director within 30 days from the client signing the consent to treatment. Treatment plan updates will be completed and signed by client, counselor, psychiatrist within two months of comprehensive treatment plan.
Facility director will spot check client records quarterly to ensure the records are in compliance.
The staff will be trained by 12/31/21. |