INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 1, 2021 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(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to collect feedback on completed trainings in two of three applicable personnel records reviewed.
Employee # 2 was hired as a counselor on April 7, 2016. There were several trainings completed during the facility's previous training year that were missing feedback forms.
Employee # 3 was hired as a counselor on March 7, 2019. There were several trainings completed during the facility's previous training year that were missing feedback forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will 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 a mechanism to collect feedback on completed trainings.
Facility director will ensure that trained staff will complete the required evaluation of the training attended within one week of the training attended.
Facility director will spot check staff records on a quarterly basis to make sure the staff member is in compliance. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's November 2020 through November 2021 fire drill logs, the facility failed to identify, on their drill log, whether the fire alarm or smoke detector was operative for all of the fire drills conducted from November 2020 through October 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility director will amend the fire drill logs to include fire alarm and smoke detectors are in operating order.
Facility director will audit the fire drill logs quarterly to ensure the program is in compliance |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility, which is publicly funded, and the governing body failed to make available to the public an annual report which is to include, but not limited to, a statement disclosing the names of officers, directors, and principal shareholders, when applicable.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility will post on the facility website making available to the general public an annual report which is to include, but not limited to, a statement disclosing the names of the officers, directors, and principal shareholders, when applicable.
Facility director will make sure the corrective action is implemented. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review of the facility's 2020 income tax return, the facility failed to provide documentation of an annual financial audit of the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.
The facility had been granted an exception request allowing them to forego the audit and present to Department staff a copy of their previous year tax return; however, the tax return documented that the facility's total gross income was above the threshold listed in Licensing Alert 01-11; thus, voiding the approved exception request.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility will request an exception request allowing the project to forego the audit and present to Department staff a copy of the project's previous year tax return. The project will present a previous tax return indicating the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.
If the exception is not granted, then the project will have an outside agency perform the financial audit of the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.
Facility director will ensure the corrective action is implemented
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed.
Client # 4 was admitted to the outpatient level of care on January 19, 2021 and was discharged on May 12, 2021. There was documentation of disclosures to a school guidance counselor on January 29, 2021, February 8, 2021, April 15, 2021, and April 19, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client # 7 was admitted to the outpatient level of care on October 7, 2021 and discharged on November 1, 2021. There was documentation of disclosures to a second funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This is a repeat citation from the October 15, 2020 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility director will ensure all of the releases in the clinical records for clients in the drug and alcohol program meet the requirements for PA code 255.5
The facility director will have a training January 6, 2022 to make sure the staff is trained regarding obtaining consents to release information from the client.
Facility director will spot check charts on a quarterly basis to make sure the client records are present and in compliance to PA code 255.5. The facility director will have a training January 6, 2022. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent to release forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in five of seven client records reviewed.
Client # 1 was admitted to the outpatient level of care on October 11, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on October 11, 2021 that allowed for the release of assessment and evaluations, entire mental health record, psychosocial history, and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 3 was admitted to the outpatient level of care on October 15, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on October 15, 2021 that allowed for the release of assessment and evaluations, entire mental health record, psychosocial history, and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 4 was admitted to the outpatient level of care on January 19, 2021 and was discharged on May 12, 2021. A release of information form to a funding source was signed and dated by the client on January 18, 2021 that allowed for the release of assessment and evaluations, entire mental health record, psychosocial history, and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 6 was admitted to the outpatient level of care on August 24, 2021 and was discharged on October 25, 2021. A release of information form to a funding source was signed and dated by the client on August 24, 2021 that allowed for the release of assessment and evaluations, entire mental health record, psychosocial history, and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 7 was admitted to the outpatient level of care on October 7, 2021 and was discharged on November 1, 2021. A release of information form to a funding source was signed and dated by the client on October 7, 2021 that allowed for the release of assessment and evaluations, entire mental health record, psychosocial history, and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will ensure all of the releases in the clinical records for clients in the drug and alcohol program meet the requirements for PA code 255.5.
Facility director will spot check charts on a quarterly basis to make sure the client records are in compliance to PA code 255.5. The facility director will have a training during the staff meeting on January 6, 2022. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to assure that a copy of a client consent to release information form was offered to the client in six of seven client records reviewed.
Client # 1 was admitted to the outpatient level of care on October 11, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on October 11, 2021 and there was no documentation that a copy was offered to the client.
Client # 2 was admitted to the outpatient level of care on October 13, 2021 and was still active at the time of inspection. A release of information form to a person was signed and dated by the client on October 11, 2021 and there was no documentation that a copy was offered to the client.
Client # 3 was admitted to the outpatient level of care on October 15, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on October 15, 2021 and there was no documentation that a copy was offered to the client.
Client # 4 was admitted to the outpatient level of care on January 19, 2021 and was discharged on May 12, 2021. A release of information form to a funding source was signed and dated by the client on January 18, 2021 and there was no documentation that a copy was offered to the client. Additionally, a release of information form to a person was signed and dated by the client on January 19, 2021 and there was no documentation that a copy was offered to the client.
Client # 6 was admitted to the outpatient level of care on August 24, 2021 and was discharged on October 25, 2021. A release of information form to a funding source was signed and dated by the client on August 24, 2021 and there was no documentation that a copy was offered to the client.
Client # 7 was admitted to the outpatient level of care on October 7, 2021 and was discharged on November 1, 2021. A release of information form to a funding source was signed and dated by the client on October 7, 2021 and there was no documentation that a copy was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will make sure that all of the releases in the clinical records for clients in the drug and alcohol program meet the requirements for PA code 255.5 and are completely filled out by the client and the staff. The consent will indicate whether or not the client accepted or refused a copy of the consent.
Facility director will spot check charts on quarterly basis to make sure they are in compliance to PA code 255.5. The facility director will have a training during the staff meeting on January 6, 2022. |