INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 10, 2023 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
|
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.
|
Observations
Based on a review of personnel records, the facility failed to document at least 25 hours of training for each counselor for the January 1, 2022 through December 31, 2022 training year.
Employee #2 was hired as a counselor on March 7, 2019 and had documentation of 20 hours of training for the 2022 training year.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will have a staff training on the importance of obtaining 25 hours of training during a staff meeting by 11/2/23.
Facility director will audit training records on quarterly basis to ensure compliance. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on the physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed as a space heater was discovered in the owner's office.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will have a staff meeting to discuss that all heaters need to be permanently mounted or installed and any other type will be not permitted on the premises by 11/2/23.
The heater that was discovered during the last audit was taken out of the office. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on a review of the facility's November 2022 through September 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's hours of operation are Monday through Thursday 10:00AM - 9:00PM and Friday 10:00AM - 6:00PM. None of the drills, conducted during the reviewed period, were completed during the facility's morning hours of operation.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will ensure that all of the practice times are included in the fire drills to include the morning hours to make sure the facility is practicing during the facilities hours of operation of Monday through Thursday 10:00AM- 9:00PM and Friday 10:00AM - 6:00PM.
Facility Director will audit the logs on a quarterly basis to ensure compliance with all staffing shifts. |
709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
|
Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop a written plan providing for outreach services which shall include, but not be limited to, identifying persons in need of project services.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will develop a written plan providing for outreach services which shall include, but not limited to, identifying persons in need of project services no later than 11/3/23. |
709.94(f)(2) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
|
Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop a written plan providing for outreach services which shall include, but not be limited to, alerting persons and their families to the availability of project services.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will develop a written plan providing for outreach services which shall include, but not limited to, alerting persons and their families to the availability of project services no later than 11/3/23.
|
709.94(f)(3) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
|
Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop a written plan providing for outreach services which shall include, but not be limited to, encouraging persons to utilize the service delivery system.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility director will develop a written plan providing for outreach services which shall include, but not limited to, encouraging persons to utilize the service delivery system no later than 11/3/23.
|