INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26 and 27, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. 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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705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 F. Additionally, the facility failed to provide privacy in toilets with required doors.
The findings included:
The physical plant inspection took place on March 27, 2014, at approximately 10:30 a.m. The water temperature was tested in the staff bathroom and shower in a patient bedroom on the dual diagnosis unit on 2A. The temperature read 130 F. The maintenance manager confirmed the temperature.
The bedrooms and bathrooms were inspected. The facility used curtains for the entrance to the toilet area.
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Plan of Correction
The Director of Plant Operations checked and adjusted all thermostats to 120 degrees. The Director of Plant Operations or designee, will check temperatures on a monthly basis to ensure ongoing compliance.
The Horsham Clinic has submitted a written letter to the Division Director, dated 4/28/14, requesting an exception and approval to continue the use of curtains on patient bathrooms due to the psychiatric needs and high risks inherent in the population served.
The Director of Quality Improvement is responsible for investigating other safe options to facilitate compliance and will be responsible for reporting the status monthly to the EOC Committee until the exception is approved or compliance with the standard is met. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on the physical plant inspection, the facility failed to ensure that a portable fire extinguisher was accessible to all staff.
The findings included:
The physical plant inspection took place on March 27, 2014, at approximately 10:30 a.m. The fire extinguishers are located in a locked cabinet on each floor. During the tour, it was requested that each cabinet be opened for review of the fire extinguisher.
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Plan of Correction
The Director of Quality Improvement has submitted a Request for Exception to Division Director. The Directors of Quality Improvement and Plant Operations are responsible to investigate safe alternatives and report to the EOC committee on a monthly basis until the exception is approved or compliance with standard is met. |
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 upon the review of the fire drill records, the facility failed to document a fire drill during hours of sleep at least every 6 months and to prepare alternate exit routes to be used during fire drills.
The findings included:
Fire drill logs for the time period of May 2013 to March 2014 were reviewed. Ten months of fire drill logs were reviewed for two buildings. The facility documented three times for fire drills, 6:45 a.m., 1:15 p.m. and 4:15 p.m. Based on the patient schedule, the patients were sleeping between 11:30 p.m. and 6:45 a.m. The facility did not document a fire drill during the patients hours of sleep.
The 2A building fire drill logs from June 2013 to February 2014 identified the use of only the main exit on all logs. The 2B building fire drill logs from May 2013 to December 2013 identified the use of only the main exit on all logs.
The findings were reviewed and confirmed by the project director and human resources manager.
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Plan of Correction
The Director of Plant Operations has retrained all his staff regarding the need to conduct a fire drill at 6:30am (during sleeping hours) at least once a quarter and to use multiple exits during the drills. Fire drills will be reviewed by the EOC committee, on a monthly basis, to ensure ongoing compliance. |
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 the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in three of ten records. Additionally, the facility failed to adhere to 4 Pa Code 255.5 in ten patient records reviewed.
The findings included:
Ten patient records were reviewed during the on-site inspection. Eight patient records were reviewed for consents to release information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in records, # 3, 4 and 5.
Additionally, the facility did not provide an informed and voluntary consent to release information to adhere to 4 Pa code 255.5 in all records for the patient's funding source. The consent to release provided did not limit the disclosure.
4 Pa. Code 255.5 (b) states:
(b) Restrictions. Information released to judges, probation or parole officers,
insurance company health or hospital plan or governmental officials, under subsection
(a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability
of continuing the client with the assigned project and shall be restricted to
the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or
alcohol abuse and the frequency of such relapse.
Patient record # 3 contained a consent to release information for the emergency contact that did not identify the information to be disclosed, an expiration date, the patient receipt of copy, a witness signature and date, nor the date of the patient signature.
Patient record # 4 contained a release dated 3/24/2014 that did not identify the information to be disclosed or the purpose for the disclosure. Additionally, a consent dated 3/24/2014 identified the purpose as continuity of care and did not identify to whom the disclosure would be made or the information to be disclosed.
Patient record # 5 contained a release for a probation officer dated 3/6/2014 that included the disclosure of the aftercare plan. This disclosure exceeds 4 Pa Code 255.5.
The findings were reviewed and confirmed with the clinical supervisor.
This is a repeat deficiency from the May 3, 2013 on-site renewal visit.
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Plan of Correction
The facility Privacy Officer will meet with the admissions staff and the social work staff, within the next 30 days, and re-train them in the limitations set forth in 4 Pa Code 255.5 and the proper completion of release forms. The Directors of Admission and Social Work will each audit 40 active charts each month to ensure ongoing compliance. Results of the audits will be discussed and reviewed by the Performance Improvement Committee. |