INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11, 2023 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually during the facility's June 2021 through May 2022 training year in one of four applicable personnel records reviewed.
Employee #7 was hired as a counselor on September 28, 2020. The personnel record documented 21 hours of annual training during the training year reviewed.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The required training hours for all staff will be required and monitored by Horsham's Human Resources Department.
All Personnel Files will be audited for compliance with training hours and reported to the Performance Improvement Committee.
All staff requesting accommodations with the required training hours will notify their direct supervisor and Project leadership will apply for the appropriate waiver. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in two of fourteen client records reviewed.
Client #4 was admitted to the Psychiatric Hospital Detoxification activity on December 2, 2022 and was discharged on December 5, 2022. A release of information form to a physician was signed and dated by the client on December 2, 2022; however, the name of the physician, agency or organization was not documented on the form.
Client #9 was admitted to the Psychiatric Hospital Residential activity December 5, 2022 and was discharged on December 7, 2022. A release of information form to a physician was signed and dated by the client on December 2, 2022; however, the name of the physician, agency or organization was not documented on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was initiated on 4/26/23 by the Director of Admissions and the Director of Performance Improvement to all admissions clinical staff on the proper completion of release of information forms including the name of the person, agency, or organization to whom a disclosure was to be made.
Any clinical staff member that was not able to attend the scheduled trainings did so on or before their next worked shift to assure understanding.
On-going the Director of Admissions or designee will monitor through monthly chart audits to ensure full and proper completion of all release of information documents as per policy. Compliance data of the audits will be reported monthly to the Performance Improvement Committee |
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.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on a consent form in one of fourteen client records reviewed.
Client #1 was admitted to the Psychiatric Hospital Detoxification activity on November 26, 2022 and was discharged on December 1, 2022. A release of information form to an emergency contact was signed and dated by the client on November 26, 2022; however, the specific information to be disclosed was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was initiated on 4/26/23 by the Director of Clinical Services and the Director of Performance Improvement to all clinical staff on the proper completion of consent forms including documentation of the specific information to be released.
Any clinical staff member that was not able to attend the scheduled trainings did so on or before their next worked shift to assure understanding.
On-going the Director of Admissions or designee will monitor through monthly chart audits to ensure full and proper completion of all release of information documents as per policy. Compliance data of the audits will be reported monthly to the Performance Improvement Committee |
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 record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent was offered to the client in three of fourteen client records reviewed.
Client #1 was admitted to the Psychiatric Hospital Detoxification activity on November 26, 2022 and was discharged on December 1, 2022. There were release of information forms to an emergency contact and a funding source that were signed and dated by the client on November 26, 2022; however, there was no documentation that a copy of both forms were offered to the client.
Client #4 was admitted to the Psychiatric Hospital Detoxification activity on December 2, 2022 and was discharged on December 5, 2022. There were release of information forms to a physician, an emergency contact, and a funding source that were signed and dated by the client on December 2, 2022; however, there was no documentation that a copy of any of the forms were offered to the client.
Client #9 was admitted to the Psychiatric Hospital Residential activity on December 5, 2022 and was discharged on December 7, 2022. There were release of information forms to a physician, an emergency contact, and a funding source that were signed and dated by the client on December 2, 2022; however, there was no documentation that a copy of any of the forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was initiated on 4/26/23 by the Director of Clinical Services and the Director of Performance Improvement to all clinical staff on the proper completion of consent forms including the documentation that indicates patients are provided copies of all completed forms.
Any clinical staff member that was not able to attend the scheduled trainings did so on or before their next worked shift to assure understanding.
On-going the Director of Admissions or designee will monitor through monthly chart audits to ensure full and proper completion of all release of information documents as per policy. Compliance data of the audits will be reported monthly to the Performance Improvement Committee |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in fourteen of fourteen client records reviewed.
In every client record reviewed, the non-discrimination rights acknowledgement form was missing ethnicity, marital status, and sexual orientation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A policy and document review was conducted by The Director of Performance Improvement on the requirement to document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
The non-discrimination right acknowledgement form was revised (and implemented) to reflect ethnicity, marital status, and sexual orientation on 4/12/23.
Moving forward, the PI department will audit for compliance to ensure the non-discrimination rights acknowledgement form includes ethnicity, marital status, and sexual orientation. |