INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 9, 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 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(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, 2022 through December 31, 2022 training year.
Employee #2 was hired as a counselor on April 7, 2014. The personnel record had documentation of 20.25 hours of training for the reviewed training year.
This is a repeat citation from the November 10, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure that any staff who is unable to complete their required 25 clock hours of training due to medical leave has a waiver requesting exemption completed to ensure compliance.
The facility director will audit the staff records on an annual basis in November of the training year to ensure the staff are completing their training requirements prior to the end of the training cycle.
The facility director will inform the staff during their staff meeting to discuss the importance of completing the training hours and be reminded of the training resources available no later than 11/24/23. |
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.
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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 60 days in one of one applicable client records reviewed.
Client #1 was admitted on August 11, 2022 and was discharged on November 23, 2022. The comprehensive treatment and rehabilitation plan was completed on September 6, 2022 and the first update was due no later than November 6, 2022; however, the update was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will have a training during the next clinical staff meetings to make sure the staff are aware of the program policies and state regulations indicating treatment plan updates need to be completed and signed by the client, counselor, and psychiatrist within two months of the comprehensive treatment plan.
The facility director will spot check the charts on a bimonthly basis to ensure the client records are in compliance.
The staff will be trained by 11/30/23 |