INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25-26, 2008 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on April 21 , 2008.
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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 the employee records during the onsite licensing inspection held March 25-26, 2008 the facility failed to document training evaluation forms in accordance with agency policy which requires that each employee submit a training evaluation form after each training attended. Training evaluation forms were missing from employee files # 3, 5, 6, 7 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.123(b)(2) LICENSURE Tx Plan Update
709.123. Treatment and rehabilitation.
(b) Treatment and rehabilitation services.
(2) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of the client records during the onsite licensing inspection held March 25-26, 2008, the facility failed to document a treatment plan update in one of one applicable client records, specifically client record # 5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Follow-up information.
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Observations
Based on a review of the client records during the onsite licensing inspection held March 25-26, 2008, the facility failed to document that follow up was completed in accordance with agency policy in one of two applicable client records, specifically client record # 1.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a review of the physical plant during the onsite licensing inspection held March 25-26, 2008 the facility failed to ensure that each bathroom had a working exhaust fan. Patient room numbers 127 and 128 did not have windows or operating exhaust fans at the time of the inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a review of the physical plant during the onsite licensing inspection held March 25-26, 2008, the facility failed to ensure cleanliness of patient bathrooms . Mildew was noted in the shower stall grout in rooms # 127 and 128.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the staff training records during the onsite licensing inspection held March 25-26, 2008, the facility failed to ensure that all staff are trained in fire extinguisher use. No documentation was on file to support that employees # 3 and 7 received the required training.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs during the onsite licensing inspection held March 25-26, 2008, the facility failed to conduct monthly fire drills between June, 2007 and November, 2007.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the agency policy manual during the onsite licensing inspection held March 25-26, 2008, the facility failed to develop a written procedure for the confidentiality of client identity and records that is compliant with state law at 71 P. S. Subsection 1690.108 and state regulations at 4 Pa. Code Subsection 255.5 and 28 Pa. Code Subsection 709.28 as well as the federal regulations at 42 CFR Part 2, Subparts A through E. The policy as written addresses a duty to warn, which is not consistent with the regulation at 42 CFR Part 2, Subpart E, subsection 2.63(a)(1). Agency policy also incorrectly addressed consent of minors stating that release of information for those under fourteen years of age needed to be signed by the parent or guardian. This statement is in direct contradiction to state law at 71 P. S. Subsection 1690.112 and the federal companion regulation at 42 CFR Part 2, Subpart B, Subsection 2.14(b). The construction of the consent to release information form was confusing in that the form has the client giving permission for the treatment facility to release information to another entity and at the same time gives the treatment facility "permission" to obtain the same information, for the same purpose, from that entity. The construction is not logical or conducive to the concept of informed consent..
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of the client records during the onsite licensing inspection held March 25-26, 2008, the facility failed to consistently document an informed consent to treatment. The form entitled "Conditions of Admission Form" includes section # 9 which contained a general consent to release information to third party payers in each of the five client records reviewed, specifically client records #1, 2,3,4, 5. The language in this consent permitted the disclosure of "any information that is contained in the client medical record." This language constitutes a "general" consent to release information which is prohibited at 42 CFR Part 2 Subpart C, Subsection 2.32 and it fails to meet the condition of an "informed consent" as required at 28 Pa. Code Subsection 709.28(c).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of the client records during the onsite licensing inspection held March 25-26, 2008, the facility failed to document specific information to be disclosed in client records # 1, 2, 3, 4 and 5. In each of the five client records reviewed consents to release information were documented which identified "verbal communication" or "complete medical record" as the specific information to be released. Such phrases constitute "general" consents to release information which are prohibited at 42 CFR Part 2, Subpart C, Subsection 2.32.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 records.
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Observations
Based on a review of the client records during the onsite licensing inspection held March 25-26, 2008, the facility failed to document that client's were offered a copy of each consent. The check-off boxes used on the form to document that each client was offered a copy of each consent were not checked consistently on the consent to release information forms in client records # 1, 2, 3, 4 and 5 ( five of five records reviewed).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on a review of the administrative records during the onsite licensing inspection held March 25-26, 2008, the facility failed to document a written policy which addressed the client's right to appeal a decision limiting access to his/her records.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |