INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3, 2010 and March 4, 2010 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 and a plan of correction is due on March 31, 2010.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on staff interviews, staff development records and a review of the staffing requirements facility summary report, the facility failed to appoint a lead counselor for supervision of counseling positions in excess of 8 full time equivalent (FTE) positions.
Findings:
A review of the staffing requirements facility summary report, staff development records and interviews on March 4, 2010 verified that the facility employs 9.2 FTE counselor and counselor assistant positions. The full-time clinical supervisor is responsible for the supervision of eight counselors. A lead counselor has not been appointed for supervision for the 1.2 FTE counseling positions in excess of the 8 FTE positions.
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Plan of Correction
A lead counselor will be appointed for the supervision of the FTE counseling positions over the 8 full time equivalent positions. The full-time clinical supervisor will continue to supervise 8 FTE counselor positions. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, patient schedules and interviews, the facility failed to conduct a fire drill during sleeping hours every 6 months.
Findings:
Fire drill logs reviewed on March 3, 2010 for the period of January 30, 2009 through February 3, 2010 failed to include documentation of a fire drill during patient sleeping hours. Patient sleeping hours are defined on the client program schedule of March 4, 2010 as 23:30 through 06:45.
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Plan of Correction
Effective immediately, fire drills during sleeping hours will be conducted by the maintenance department after 11:30pm or prior to 6:45am once every 6 months. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a physical plant inspection, review of patient records and a review of patient rights procedures, the facility failed to demonstrate efforts toward informing the patients of their rights to review the medical records, rebut some of the content of the medical record or submit memorandum to the medical record.
Findings:
Eight of eight patient records reviewed on March 4, 2010 failed to include documentation of the patients' orientation to their right to review the medical record, request correction of the medical record or submit rebuttal information to the medical record. A physical plant inspection on March 3, 2010 revealed that the facility failed to document the posting of patients rights on the patient information board regarding the right to review, submit or correct the medical record.
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Plan of Correction
A posting on the patient information board has been added to include the right of patient's to review their medical record, request correction of the medical record or submit rebuttal information to the medical record. |