INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection monitoring conducted on April 21, 2022 through April 22, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Horsham Clinic 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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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 complete an informed and voluntary consent to release information form prior to the disclosure of information in eleven of fifteen client records reviewed. Client # 1 was admitted to the Psychiatric Hospital Detoxification activity on April 18, 2022 and was still active at the time of the inspection. There was evidence of disclosures to the 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 any of the disclosures. Client # 3 was admitted to the Psychiatric Hospital Detoxification activity on November 2, 2021 and was discharged on November 7, 2021. There was evidence of disclosures to the 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 any of the disclosures. Client # 4 was admitted to the Psychiatric Hospital Detoxification activity on March 27, 2022 and was discharged on March 30, 2022. There was evidence of disclosures to the 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 any of the disclosures. Client # 5 was admitted to the Psychiatric Hospital Detoxification activity on April 10, 2022 and was discharged on April 16, 2022. There was evidence of disclosures to the 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 any of the disclosures. Client # 6 was admitted to the Psychiatric Hospital Detoxification activity on October 20, 2021 and was discharged on October 24, 2021. There was evidence of disclosures to the 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 any of the disclosures. Client # 8 was admitted to the Psychiatric Hospital Residential activity on April 10, 2022 and was still active at the time of the inspection. There was evidence of disclosures to the 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 any of the disclosures. Client # 9 was admitted to the Psychiatric Hospital Residential activity on April 16, 2022 and was still active at the time of the inspection. There was evidence of disclosures to the 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 any of the disclosures. Client # 10 was admitted to the Psychiatric Hospital Residential activity on March 30, 2022 and was still active at the time of the inspection. There was evidence of disclosures to the 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 any of the disclosures. Client # 12 was admitted to the Psychiatric Hospital Residential activity on October 25, 2021 and was discharged on November 1, 2021. There was evidence of disclosures to the 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 any of the disclosures. Client # 14 was admitted to the Psychiatric Hospital Residential activity on November 7, 2021 and was discharged on November 29, 2021. There was evidence of disclosures to the 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 any of the disclosures. Client # 15 was admitted to the Psychiatric Hospital Residential activity on March 14, 2022 and was discharged on March 30, 2022. There was evidence of disclosures to the 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 any of the disclosures. This is a repeat citation from the May 26, 2021 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A policy review was conducted by the Director of Performance Improvement on the requirements of a present release of information within the medical record to release of information.
Training was initiated on 4/25/22 by the Director of Admissions and the Director of Performance Improvement to all admissions clinical staff on the implementation of a release of information as well as the proper completion of such forms as detailed in facility policy.
Any clinical staff member that was not able to attend the scheduled trainings did so on or before their next worked shift to assure understanding.
On-going the Director of Admissions or designee will monitor through monthly chart audits to ensure full and proper completion of all release of information documents as per policy. Compliance data of the audits will be reported monthly to the Performance Improvement Committee
All patients selected for the chart audit have been discharged from the facility. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record in fifteen of fifteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include notification of this regulatory client right.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services revised the patient Bill of Rights document to include a statement indicating the project, facility director may temporarily remove portions of the record prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and the reason for removing sections shall be documented in the record |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in fifteen of fifteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include notification of this regulatory client right.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services revised the patient Bill of rights document to include a statement indicating their right to appeal a decision limiting access to their records to the director |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in fifteen of fifteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include notification of this regulatory client right.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services revised the patient Bill of Rights document to include a statement indicating their right to request the correction of in accurate, irrelevant, outdated, or incomplete information in their records. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in fifteen of fifteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include notification of this regulatory client right.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services revised the patient Bill of Rights to include a statement indicating their right to submit rebuttal data or memoranda to their own records |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's May 2021 through April 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident at the facility of a physical assault involving clients on February 25, 2022This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/25/22, the Director of Performance Improvement reviewed the facility policy regarding the reporting of unusual incidents to confirm the policy aligned with state requirements.
The Facility Director re-educated and re-trained the Nurse Manager on reporting of the unusual incidents through the online portal within the required 3 business days on 4/22/22
Timely reporting per facility policy continues to be monitored monthly to ensure continued compliance. For reporting that does not not meet timely requirements per facility policy, immediate action will be taken up to and including disciplinary action. Timely reporting of data and compliance rates will be reported monthly to the Performance Improvement Committee for a period of 90 days for tracking, trending and to assure compliance with policy. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's May 2021 through April 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility on February 25, 2022This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/25/22, The Director of Performance Improvement reviewed the facility policy regarding the reporting of unusual incidents to confirm the policy aligned with state requirements.
The facility Director re-educated and re-trained Nurse Manager on reporting unusual incidents through the online portal within the required business days on 4/22/22.
Timely reporting per facility policy continues to be monitored monthly to ensure continued compliance. For reporting that does not meet timely requirements per facility policy, immediate action will be taken up to and including disciplinary action. Timely reporting of data and compliance rates will be reported monthly to the Performance Improvement Committee for a period of 90 days for tracking, trending to ensure compliance with policy. |