INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 17, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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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704.12(a)(2) LICENSURE InPat. Hosp Detox
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(2) Inpatient hospital detoxification. There shall be one FTE primary care staff person available for every five clients during primary care hours.
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Observations
Based on a review of the facility's Staffing Requirement Summary Report, the facility failed to provide one FTE primary care staff person for every five clients during primary care hours for clients in the inpatient hospital detoxification activity for the week of March 1, 2020 through March 7, 2020.
On March 1, 2020 the census at the facility was 27 clients. This required six primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m. - 7:00 a.m., there were two staff available during these hours.
3:00 p.m. - 11:00 p.m., there were five staff available during these hours.
11:00 p.m. - 12:00 a.m., there were two staff available during these hours.
On March 2, 2020 the census at the facility was 28 clients. This required six primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m. - 7:00 a.m., there were two staff available during these hours.
11:00 p.m. - 12:00 a.m., there were two staff available during these hours.
On March 3, 2020 the census at the facility was 23 clients. This required five primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m. - 7:00 a.m., there were two staff available during these hours.
3:00 p.m. - 11:00 p.m., there were four staff available during these hours.
11:00 p.m. - 12:00 a.m., there were two staff available during these hours.
On March 4, 2020 the census at the facility was 21 clients. This required five primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m. - 7:00 a.m., there were two staff available during these hours.
11:00 p.m. - 12:00 a.m., there were two staff available during these hours.
On March 5, 2020 the census at the facility was 22 clients. This required five primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m. - 7:00 a.m., there were two staff available during these hours.
3:00 p.m. - 11:00 p.m., there were four staff available during these hours.
11:00 p.m. - 12:00 a.m., there were two staff available during these hours.
On March 6, 2020 the census at the facility was 16 clients. This required four primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m. - 7:00 a.m., there were two staff available during these hours.
11:00 p.m. - 12:00 a.m., there were two staff available during these hours.
On March 7, 2020 the census at the facility was 23 clients. This required five primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m. - 7:00 a.m., there were two staff available during these hours.
3:00 p.m. - 11:00 p.m., there were four staff available during these hours.
11:00 p.m. - 12:00 a.m., there were two staff available during these hours.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
These finding were reviewed by the Project Director with the Medical Director, Facility Director, Clinical Director, CEO and staffing coordinator. On a daily basis, the Medical Director (or his designee) will provide a report to the staffing coordinator that contains the number of patients on detoxification protocols. The staffing coordinator will ensure that there are no less than one FTE Primary Care Staff person assigned to each shift for every five patients on detoxification protocols. The Facility Director will oversee the schedule to ensure this standard is met each shift. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 April 2019 through February 2020 fire drill logs, the facility failed to include, on the fire drill log, which exit route was used during every drill conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Environment of Care (EOC) Director reviewed this finding with all staff responsible for conducting fire drills have reviewed Chapter 705.10 (d)(4). Each staff member has signed an attestation they have reviewed and understand all fire drill records must include the date, time of drill, time it took for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
After each fire drill form is submitted, the EOC Director will review the form in its entirety to ensure the exit route is properly documented. All fire drill logs will be reviewed in the monthly Environment of Care Committee meeting. Any deficiencies will be addressed by the EOC Director and the staff member completing the form will be retrained and if warranted, receive disciplinary action. |