INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2023, staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Brighter Visions Counseling 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(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the facility's staff development program the annual assessment is to be completed via anonymous questionnaire and subsequent group discussion by stakeholders. During the administrative review the facility failed to document an annual assessment of the staff training needs for the training year of January 1, 2023 through December 31, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Brighter Visions Counseling acknowledges and pledges compliance with §704.11 (c)(1)(2). A questionnaire will be provided to each staff member by December 10 for their input into the training plan to be collected by December 20. This questionnaire will be developed, circulated, and collected by the Facility Director. A plan of training will then be developed by January 1. This plan has been launched for completion by January 1, 2024. The application of this plan of correction is the responsibility of the Director. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility ' s staff development program, the annual training plan is to be developed January 1 of each year. During the administrative review the facility failed to document an overall plan for addressing staff training needs for the training year of January 1, 2023 through December 31, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Brighter Visions Counseling acknowledges and pledges compliance with §704.11 (c)(1)(2). Each year an overall training plan shall be developed with staff input by January 1 for that year. This plan shall be developed and documented by the Director. This POC is in place as of January 1, 2024. The Director is responsible for this implementation. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that one of three employees reviewed were instructed in the use of fire extinguishers upon employment.
Employee #3 was hired on April 6, 2023 as a counselor and was still in that position as of the date of the inspection. There was no documentation that the training occurred.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will be in compliance with Section 705.28, Fire Safety, (3) Staff use of Fire Extinguishers. Each staff member will be trained in the use of the Fire Extinguishers upon initiation of employment. This training will be documented in the staff member's personnel file. This procedure has been adopted immediately. The implementation of this POC is the responsibility of the Director. |
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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies in one of three records reviewed.
Employee #3 was hired on April 6, 2023 as a counselor and was still in that position as of the date of the inspection. There was no documentation that the training occurred.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will be in compliance with Section 705.28, Fire Safety, (d) Fire Drills. The facility Manual of Policies and Procedures contains detailed instructions for evacuation and re-assembly of occupants of the building in event of fire, flood, earthquake, and any other emergency requiring evacuation. All staff members will be trained in these procedures at the beginning of their employment, and the training will documented in each personnel file. This POC is in place immediately, and compliance is the responsibility of the Director. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to notify the Department within three days of two unusual incidents pertaining to the death of clients known by the facility for ambulatory services.
Client #7 was admitted on October 18, 2022 and was discharged on July 17, 2023. The reason listed for discharge was listed as the client was deceased. During a discussion with facility staff they reported the client ' s death was not reported to the Department and they did not have documentation of the dates but had found out through social media.
There was a second client listed as being discharged during this review period as being discharged due to being deceased that was not reviewed during this inspection. During a discussion with facility staff they reported the client ' s death was not reported to the Department and they did not have documentation of the dates but had found out through social media.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
§ 709.34. Reporting of unusual incidents. (c) To the extent permitted by State and Federal confidentiality laws, the Facility will file a written unusual incident report with the Department within 3 business days following an unusual incident involving Death or serious injury due to trauma, suicide, medication error, or unusual circumstances of any client. This policy is implemented immediately. Compliance with this policy is the responsibility of the Director. |