INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 2, 2013 to May 3, 2013 by staff from the Division of Drug and Alcohol 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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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.
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Observations
Based on a review of client records, the facility failed to document follow-up information in accordance with their policy and procedures in three of four records reviewed.
The findings include:
The facility's policy titled: "Patient Sobriety and compliance with aftercare," states:
"Prior to discharge social worker will review form "Aftercare Follow-Up Form" with the patient. The Social Worker will indicate to the patient that an employee of the hospital will contact the aftercare provider to ensure that the patient made the scheduled appointment. This will be completed within seven days of discharge from the hospital."
On May 3, 2013, four records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information according to their policy and procedures in three of four records reviewed, specifically, client records # 4, 8, and 9.
Client # 4 was admitted October 23, 2012 and was discharged November 1, 2012. The follow-up information was due November 8, 2013; however, the follow-up information was not completed until December 10, 2012.
Client # 8 was admitted October 25, 2012 and was discharged November 1, 2012. The follow-up information was due November 8, 2013; however, the follow-up information was not completed until December 10, 2012.
Client # 9 was admitted February 17, 2013 and was discharged February 25, 2013. The follow-up information was due March 4, 2013; however, the follow-up information was not completed until March 25, 2013.
The findings were confirmed during an interview with the Chief Executive Officer, project director, and facility director on May 3, 2013 at approximately 3:30 P.M.
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Plan of Correction
The Patient Sobriety and Compliance with Follow-up and Aftercare policy has been amended to state the hospital will contact the aftercare provider within seven days of the scheduled appointment. The policy was approved by the Medical Executive Committee on 5/31/13. The policy will be presented to the Governing Body at the next quarterly meeting July 19, 2013.
All clinical program staff will receive training from the Project Director or Clinical Supervisor on the change in policy by 6/30/13.
A weekly audit will be performed on all discharged clients for follow-up with the aftercare provider. Results of the audit will be forwarded to the Project Director and Clinical Supervisor for review and follow-up with the clinical staff responsible for the provider follow-up. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observations on May 3, 2013, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
A physical plant inspection was conducted on May 3, 2013. During the inspection, 9 individual counseling offices and 3 group counseling offices were inspected. From approximately 12:30 P.M. to 1:30 P.M., it was observed that some of the individual counseling offices and group counseling offices had a window on the front wall and/or front door of the counseling offices. The windows lacked any window treatments and would permit a person outside the individual counseling offices and group counseling offices to view the counseling sessions. The following are the individual counseling offices and group counseling offices with a window on the front wall and/or front office door of the counseling offices:
1)Individual counseling office room # 111 located in the Adult II B building had a window on the front wall and front office door.
2)Individual counseling office room # 115 located in the Adult II B building had a window on the front office door.
3)Individual counseling office rooms # 210, 220, 221, and 232 located in the Adult II A building had a window on the front office door of the rooms.
4)Group counseling office room # 224 located in the Adult II A building had a window on the front office door.
The findings were confirmed during an interview with the project director on May 3, 2013 at approximately 1:30 P.M.
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Plan of Correction
We submitted a letter of exception for this citation on 6/6/2013.
In the event the exception is denied, the Director of Plant Operations will place window treatments on all windows and inspect daily to ensure the window treatments are in place and that counseling sessions cannot be seen or heard outside the counseling room. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that hot food was served at or above 140 F.
The findings include:
A physical plant inspection was conducted on May 3, 2013. The Licensing Specialist asked to see a food serving temperature log during the inspection. A food serving temperature log was not presented for review. The facility was unable to provide documentation verifying that hot food at the facility had been served at or above 140 F.
The findings were confirmed during an interview with the project director on May 3, 2013 at approximately 12:31 P.M.
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Plan of Correction
A food serving temperature log will be developed for the dietary staff to document the temperature of the food for serving.
The dietary staff will be trained on the proper documentation of the hot food after it has been prepared until it is served to the clients. The staff will be trained on how to maintain the temperature at or above 140 F for all hot food served.
The food serving temperature logs will be audited weekly by the Director of the Dietary Department for compliance, who will submit the audit results to the Director of Performance Improvement quarterly. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on observations on May 3, 2013, the facility failed to have a fee schedule posted in a prominent place.
The findings include:
A physical plant inspection was conducted on May 3, 2013. It was observed during the inspection at approximately 12:30 P.M. that the facility did not have a fee schedule posted in a prominent place.
The findings were confirmed during an interview with the project director on May 3, 2013 at approximately 12:31 P.M.
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Plan of Correction
A fee schedule has been posted in the Admissions Department and in both program areas. The Project Director will monitor the Admissions Department and both program areas for continued 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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client that includes specific information disclosed, and/or if a copy of the client consent was offered to a client in five of six records reviewed.
The findings include:
On May 3, 2013, six client records requiring documentation of an informed and voluntary consent for the disclosure of information were reviewed. The facility did not obtain an informed and voluntary consent from the client for the disclosure of information contained in the record that included the specific information disclosed and/or if a copy of the client consent was offered to a client in five of six records reviewed, specifically, client records # 1, 2, 3, 4, and 6.
Client record # 1 contained a consent to release information to an organization dated 4/28/13; however, the consent form did not include the specific information disclosed.
Client record # 2 contained a consent to release information to the client's step sister dated 4/29/13; however, the facility could not provide documentation verifying that a copy of the consent was offered to client # 2. Additionally, the facility was unable to provide documentation that the client was informed of their right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, any other documentation in client record # 2.
Client record # 3 contained a consent to release information to an organization dated 4/28/13; however, the facility could not provide documentation verifying that a copy of the consent was offered to client # 3. Additionally, the facility was unable to provide documentation that the client was informed of their right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, any other documentation in client record # 3.
Client record # 4 contained an informed and voluntary consent to the client's Primary Care Physician dated 10/23/12; however, the facility could not provide documentation verifying that a copy of the consent was offered to client # 4. Additionally, the facility was unable to provide documentation that the client was informed of their right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, any other documentation in client record # 4.
Client record # 6 contained informed and voluntary consents to a government agency and an organization dated 10/27/12 and to another organization dated 10/26/12; however, the facility could not provide documentation verifying that a copy of the consent was offered to client # 6. Additionally, the facility was unable to provide documentation that the client was informed of their right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, any other documentation in client record # 6.
The findings were confirmed during an interview with the Chief Executive Officer, project director, and facility director on May 3, 2013 at approximately 3:30 P.M.
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Plan of Correction
All clinical program staff will receive training from the Clinical Supervisor in confidentiality, as defined in the
regulations, by 6/30/2013.
All clinical program staff will receive training from the Clinical Supervisor in the proper completion of a Consent to Release Information in
accordance with the regulations, including specific information to be disclosed and offering the client a copy of the consent, by 6/30/2013. Clients #1,2,3,4 and 6 have been discharged from the program. As a result, the counselors are not able to meet with clients #1,2,3,4, and 6 to properly complete new consents to release information with the clients because the clients have been discharged.
The Project Director will conduct a
random sampling of 50 Consents to
Release Information to be monitored
every month for completion and
compliance of the regulations. The
monitor will audit the information to
be released, the purpose of the
release and whether or not the client
was offered a copy of the release.
In addition, the policy for the Release of Information for Dual Diagnosis patients will be posted on the program bulletin boards. |