INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 21, 2025 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:
|
Plan of Correction
|
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.
|
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 # 2 was hired as a counselor on September 6, 2023 and was due to have the HIV/AIDS training and the TB/STD training completed no later than September 6, 2024. In the record, there was documentation indicating the HIV/AIDS training was completed; however, there was no documentation indicating the TB/STD training was completed as of the date of the inspection.
This is a repeat citation from the October 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor is planning an in-house training utilizing the curriculum approved from the Department of Drug and Alcohol for the staff who are in need of the trainings to be in compliance no later than December 31, 2025
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 #2 will sign up for the next department approved training for TB/STD no later than 12/31/2025
|
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of five applicable client records reviewed.
Client # 1 was admitted on August 30, 2025 and was still active at the time of inspection. The individual treatment plan was developed on September 3, 2025; however, there was no documentation on the plan indicating the type of treatment and rehabilitation services the client was to receive.
Client # 2 was admitted on August 12, 2025 and was still active at the time of inspection. The individual treatment plan was developed on August 13, 2025; however, there was no documentation on the plan indicating the type of treatment and rehabilitation services the client was to receive.
Client # 4 was admitted on December 4, 2024 and was discharged on March 4, 2025. The individual treatment plan was developed on December 26, 2024; however, there was no documentation on the plan indicating the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 5 was admitted on March 13, 2025 and was discharged on April 3, 2025. The individual treatment plan was developed on March 27, 2025; however, there was no documentation on the plan indicating the type of treatment and rehabilitation services the client was to receive.
Client # 6 was admitted on July 21, 2025 and was discharged on October 10, 2025. The individual treatment plan was developed on March 27, 2025; however, there was no documentation on the plan indicating the type and frequency of treatment and rehabilitation services the client was to receive.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director is going to change the format of the treatment plans to include the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plans in the Advanced MD system (EHR) no later than 12/1/2025. The clinical team will document which type of services their individual client will receive while in the program, to indicate whether the three sessions the client is receiving weekly are one individual session and two groups, or two individual sessions and one group.
The clinical team will be trained on the new system to document the type and frequency of the treatment and rehabilitation services on the individual treatment and rehabilitation plan no later than 12/1/2025.
The facility director to ensure the client records are in compliance by doing quarterly documentation audits. |