INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on April 8, 2019 through April 10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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.
|
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
The facility failed to ensure that all staff completed mandatory 6 hours of HIV/AIDS training within the regulatory time frame based off a review of the facility's Staffing Requirement Facility Summary Report.Employee # 8 was hired as a counselor on October 30, 2017. The HIV/AIDS training was due no later than October 30, 2018 and it was not completed at the time of the inspection. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
All staff are current with their training requirements. The Clinical Supervisor will track each new hire and schedule them for their required trainings within the first 6 months of employment to ensure compliance with standard. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
The facility failed to ensure that all heater units were permanently mounted or installed. Based on a physical plant inspection conducted on April 10, 2019 at approximately 10:45 am, there was a space heater found in counseling office #221 and in counseling office #521. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
All space heaters were removed by the Director of Plant Operations during the walk through. Staff on units were re-educated regarding the standard on 4/10/2019. The Program Coordinator began weekly walk throughs of the unit offices on April 15th to ensure ongoing compliance with standard. |
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.
|
Observations
The facility failed to keep voluntary consent to release information forms within the limits established by 4 Pa. Code (b) in 13 of 15 client records reviewed. Client #1 was admitted on March 21, 2019 and was active at the time of inspection. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #2 was admitted on March 28, 2019 and was active at the time of inspection. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #3 was admitted on March 31, 2019 and was active at the time of inspection. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #4 was admitted on March 24, 2019 and was active at the time of inspection. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #6 was admitted on April 4, 2019 and was discharged on April 9, 2019. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #7 was admitted on September 4, 2018 and was discharged on September 20, 2018. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #8 was admitted on May 3, 2019 and was discharged on May 18, 2018. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #10 was admitted on April 9, 2019 and was active at the time of inspection. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #11 was admitted on April 5, 2019 and was active at the time of inspection. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #12 was admitted on October 6, 2018 and was discharged on October 19, 2018. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #13 was admitted on October 12, 2018 and was discharged on October 30, 2018. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #14 was admitted on October 3, 2018 and was discharged on October 11, 2018. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.Client #15 was admitted on December 5, 2018 and was discharged on December 12, 2018. There was an informed consent to release information form to a funding source that allowed for "all drug and alcohol information" to be released.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Magellan release of information forms were removed from document packets on 4/15/19. Horsham's release of information form, previously approved by Department, was distributed. Admissions and Social Work staff were re-educated regarding standard. Medical Records staff will monitor charts for ongoing compliance. |