INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 1-2, 2016 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of ten applicable records reviewed.
The findings include:
Ten personnel records which required documentation of mandatory communicable disease training were reviewed on February 1-2, 2016. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee #1.
Employee #1 was hired July 15, 2013 as a Project Director. This employee was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by July 15, 2014. The facility failed to provide documentation that employee #1 obtain the training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
THe Project Director will complete trainings by June 1, 2016. The Clinical Supervisor will review employees' trianing records on a monthly basis to ensure compliance. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all trash, garbage and rubbish was stored in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on February 1, 2016 at approximately 1:00 pm.
One of two trash dumpster's located in the parking lot to the left of the facility did not have a cover to prevent the penetration of insects and rodents. Bags of garbage were visibly exposed to the elements.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The broken dumpster lid has been replaced. The Director of Plant Operations and his staff will visibly inspect dumpsters on a daily basis to ensure they are closed properly. |
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.
|
Observations
Based on a review of the physical plant, the facility failed to ensure that the cold food was being kept at or below 40 degrees fahrenheit and the frozen food at or below 0 degrees fahrenheit in the main cafeteria and in Unit A 2 b.
The findings include:
During the physical plant tour on February 1, 2016 at approximately 1:00 pm, the thermometer in the refrigerator in Unit A 2 b was reading 48 degrees and the freezer did not have a thermometer to check the temperature to see if it was at or below 0 degrees.
Also, the freezer in the main cafeteria was displaying 6 degrees on the outside as well as on the thermometer inside the freezer at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A thermometer was placed in the freezer of Unit 2B. In addition, the Director of Plant Operations has inspected both the refrigerator on 2B and the freezer in the main cafeteria. Readings are within expectations. Housekeeping staff will monitor the units' refrigerators/freezers on a daily basis and record temperatures on a log. The Dietary Manager will check the temperature of the walk in freezer in the cafeteria on a daily basis. If out of range, Housekeeping and Dietary will alert the Director of Plant Operations. Temperature logs will be inspected by the Director of Plant Operations during weekly environmental rounds |
709.26(b)(3) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(3) The orientation of new employes.
|
Observations
Based on a review of personnel records, the facility failed to document an annual performance evaluation in two of six applicable personnel records.
The findings include:
Six personnel records requiring documentation of an annual performance evaluation were reviewed on February 1-2, 2016. The facility failed to document an annual performance evaluation in personnel records, #1 and # 3.
Employee #1 was hired as the Project Director on July 15, 2013. There was no documentation of the completion of a performance evaluation in this employee's record at the time of the inspection.
Employee #3 was hired as the Clinical Supervisor on June 1, 2014. There was no documentation of the completion of a performance evaluation in this employee's record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Annual performance evaluations will be completed and placed in the respective HR files by 3/31/2016. The Director of Human Resources will track and monitor completion of annual performance evaluations to ensure completion. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
|
Observations
Based on a review of patient records, the facility failed to verify that individual's had reached 18 years of age prior to administration of an agent in one of six records reviewed.
The findings include:
Six narcotic treatment patient records were reviewed on February 2, 2016, to ensure the facility screened individuals prior to administration of an agent. The facility failed to verify that the individual had reached 18 years of age in record # 7.
Patient # 7 was admitted to the program on August 4, 2015 and discharged on August 8, 2015. Patient # 7 was prescribed 25 mg of methadone on August 4, 2015. The facility failed to provide documentation that patient # 7 had been screened prior to administration of an agent.
The findings were reviewed with facility staff during the monitoring inspection.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the March 17-18, 2015 licensing inspection. The facility's plan of correction was submitted on April 13, 2015 and approved on April 30, 2015.
|
Plan of Correction
All efforts will be made to verify a paient's age either via photo identification, family, friend, etc. Efforts will be documented in the medical record. The Director of Admissions will audit 10 charts weekly beginning 3/14/16 to ensure compliance. Results will be forwarded to the PI Committee on a quarterly basis. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on a review of patient records, the facility failed to verify the individual's identity, including name, address, and date of birth, and other identifying data in one of six records reviewed.
The findings include:
Six narcotic treatment patient records were reviewed on February 2, 2016, to ensure the facility screened individuals prior to administration of an agent. The facility failed to verify the individual's identity, including name, address, date of birth, and other identifying data prior to administration of an agent in record #7.
Patient #7 was admitted to the program on August 4, 2015 and discharged on August 8, 2015. Patient #7 was prescribed 25 mg of methadone on August 4, 2015. The facility failed to provide documentation that patient #7 had been screened prior to administration of an agent.
The findings were reviewed with facility staff during the monitoring inspection.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the March 17-18, 2015 licensing inspection. The facility's plan of correction was submitted on April 13, 2015 and approved on April 30, 2015
|
Plan of Correction
All efforts will be made to verify a paient's identity via photo identification, family, friend, etc. Efforts will be documented in the medical record. The Director of Admissions will audit 10 charts weekly beginning 3/14/16 to ensure compliance. Results will be forwarded to the PI Committee on a quarterly basis. |