INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 12, 2025 and March 13, 2025 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:
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on the review of personnel records, the facility failed to ensure clinical supervisors, who have not functioned for 2 years as a supervisor in the provision of clinical services, completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee # 3 was hired as a clinical supervisor on October 8, 2023 and did not have 2 years of documented clinical supervision experience prior to being hired. There was no documentation indicating the clinical supervision core curriculum training in the personnel record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The CEO, Director of Performance Improvement, and Director of Clinical Services reviewed this finding. The Director of Social Work, employee #3 enrolled on 3/24/25 to complete an online course called "Clinical Supervision Course Bundle." This course will be completed by 5/31/2025. Staff qualifications, including training needs will continue to be monitored quarterly by the Director of Human Resources. Noncompliance with Supervisor training will immediately be remediated and discussed in the facility's Performance Improvement Committee to ensure systemic concerns are mitigated. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the facility's June 2023 through May 2024 training year, in one of four applicable personnel records reviewed.
Employee # 8 was hired as a counselor on February 20, 2023. The personnel record documented 10.30 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The CEO, Director of Performance Improvement, and Director of Clinical Services reviewed this finding. All counselors were provided with education on 3/14/2025 on the requirement to complete 25 clock hours of training annually. The Director of HR, Performance Improvement, and the Clinical Services Director will be meeting on 4/7/2025 to review the current training year and to ensure training compliance before the close of the year. Quarterly meetings will occur to review training hour compliance for all DDAP unit counselors. Training compliance will be reviewed in the Performance Improvement Committee on a quarterly basis by the Director of HR. |
709.122(b)(5) LICENSURE Follow-up
709.122. Detoxification.
(b) 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.
|
Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in one of three applicable records reviewed.
Client #7 was admitted into the detoxification portion of the program on November 4, 2024 and was discharged on November 12, 2024. The client record failed to document follow up information as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The CEO, Director of Performance Improvement, and Director of Clinical Services reviewed this finding. An aftercare form follow-up spreadsheet was implemented on 3/26/2025 by the Director of Social Work. This spreadsheet will be utilized for auditing all discharged patients from DDAP licensed units to ensure that the aftercare forms are being collected, signed, and completed for all patients when applicable. Results of this audit will be reported on a quarterly basis in the Performance Improvement Committee by the Director of Social Work. |
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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of three applicable client records reviewed.
Client #13 was admitted into the residential treatment and rehabilitation portion of the program on May 9, 2024 and was discharged on June 4, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client #14 was admitted into the residential treatment and rehabilitation portion of the program on June 1, 2024 and was discharged on June 3, 2024. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The CEO, Director of Performance Improvement, and Director of Clinical Services reviewed this finding. An aftercare form follow-up spreadsheet was implemented on 3/26/2025 by the Director of Social Work. This spreadsheet will be utilized for auditing all discharged patients from DDAP licensed units to ensure that the aftercare forms are being collected, signed, and completed for all patients when applicable. Results of this audit will be reported on a quarterly basis in the Performance Improvement Committee by the Director of Social Work. |