INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4, 2024 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:
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee # 3 was hired as a clinical supervisor on February 17, 2024. There was no documentation in the personnel record indicating the employee had clinical supervision experience prior to being hired. Additionally, there was no documentation the employee completed a Department-approved core curriculum in clinical supervision at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure clinical supervisors who do not have two years as a supervisor in the provision of clinical services will complete a department-approved core curriculum in clinical supervision to stay in compliance with the regulations. The facility director will do quarterly checks of staff trainings for any staff member identified as a clinical supervisor.
Employee #3 will attend the Department-approved core curriculum in clinical supervision no later than 12/31/24.
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in the position in one of one applicable personnel record reviewed.
Employee # 3 was hired as a clinical supervisor on February 17, 2024. There was no documentation, in the personnel record, indicating monthly clinical supervision meetings were completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will ensure clinical supervisors participate in documented monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in the position. Check training logs quarterly.
Director will start the meetings no later than 10/31/24 to ensure compliance with employee #3 |
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 all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health-related topics training within the regulatory timeframe in one of one applicable personnel record reviewed.
Employee # 4 was hired as a counselor on May 23, 2023 and was due to have the HIV/AIDS training and the TB/STD training completed no later than May 23, 2024. There was documentation the HIV/AIDS training was completed; however, there was no documentation showing at least 4 hours of TB/STD training was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure all newly hired staff presents certificates to indicate the required 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training certificate and if they have not had the training, they will have three months to complete the required training. The facility director will ensure the newly hired staff will have access to training sites to meet the requirements.
The facility director will check and follow up with the newly hired staff to ensure they have completed the required training and sent the facility director the training certificate for 6 hours of HIV/AIDS training, in addition to the 4 hours of TB/STD training certificate. The facility director will also collect the satisfaction surveys of the trainings.
The facility director will conduct the follow up six months from the date of newly hired staff.
Employee #3 will sign up for the next department approved training for TB/STD no later than 11/30/24
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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 each counselor completed at least 25 clock hours of annual training, during the facility ' s January 1, 2023 through December 31, 2023 training year, in one of one applicable personnel record reviewed.
Employee # 2 was hired as a counselor on March 7, 2019. There was only 22 hours of completed trainings documented during the training year reviewed.
This is a repeat citation from the October 10, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will have a staff training on the importance of obtaining 25 hours of training during a staff meeting by 10/23/24.
Facility director will audit training records on quarterly basis to ensure compliance.
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