INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 19, 2018 through April 20, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training for counselors during the facility's 6/01/16 through 5/31/17 training year in 5 employee records.
Employee #8 was hired as a counselor on 12/14/14 and was still in that position at the time of inspection. The record for employee #8 only documented 15.5 training hours for the training year reviewed.
Employee #9 was hired as a counselor on 6/11/06 and was still in that position at the time of inspection. The record for employee #9 only documented 10 training hours for the training year reviewed.
Employee #10 was hired as a counselor on 5/22/11 and was still in that position at the time of inspection. The record for employee #10 only documented 3.5 training hours for the training year reviewed.
Employee #11 was hired as a counselor on 4/23/08 and was still in that position at the time of inspection. The record for employee #11 only documented 5 training hours for the training year reviewed.
Employee #12 was hired as a counselor on 3/9/15 and was still in that position at the time of inspection. The record for employee #12 only documented 16 training hours for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All dual staff were re-educated via a staff meeting on 4/23/18 regarding the training requirement. Horsham Clinic utilizes a web based education platform called Healthstream to provide training to all its employees. In addition, Horsham has purchased a subscription to Quantum Education in order to ensure that the dual staff obtain the required internal and external training hours. The Director of Staff Development is the administrator for both education platforms and monitors compliance with education requirements. As of 5/11/18, all counselors have obtained the necessary training hours for the current training year (6/1/2017-5/31/2018). |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted on April 20, 2018 at approximately 1:00 pm, it was observed that there were 2 space heaters not permanently installed in the dietary manager's office, which was located just off the kitchen.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The space heaters were removed the day of discovery. Dietary manager was re-educated via a 1:1 with the Director of Plant Operations on 4/20/18. The Environment of Care (EOC) Committee, headed by the Director of Plant Operations, conducts weekly rounds of the facility and added this to their checklist in order to ensure ongoing compliance with standard. |
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
A review of the July 2017 through March 2018 fire drill logs was conducted during the licensing process. The facility conducted a total of 6 overnight fire drills during the time period of May 2017 through December 2017; however, it was documented during each overnight fire drill that the drill was a silent drill and that the facility staff failed to wake up and evacuate/assemble the patients; therefore, there was no appropriate overnight fire drill conducted during May 2017 through December 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Plant Operations was given a copy of the standard and re-educated regarding the requirement to assemble the patients at least once every 6 months during sleeping hours. Director of Plant Operations has revised his fire drill schedule and will ensure that standard is met. |
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.
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Observations
Based on the review of 11 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 7 client records.
Client #4 was admitted on 02/09/2018 and was discharged on 02/12/2018. There was documentation, as well as verification from facility staff, that the client's funding source was billed for services provided; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #5 was admitted on 11/14/2017 and was discharged on 11/22/2017. There was documentation, as well as verification from facility staff, that the client's funding source was billed for services provided; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #6 was admitted on 04/12/2018 and was still active at the time of the inspection. There was documentation, as well as verification from facility staff, that the client's funding source was billed for services provided; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #7 was admitted on 03/31/2018 and was still active at the time of the inspection. There was documentation, as well as verification from facility staff, that the client's funding source was billed for services provided; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #8 was admitted on 10/09/2017 and was discharged on 10/17/2017. There was documentation, as well as verification from facility staff, that the client's funding source was billed for services provided; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #9 was admitted on 02/12/2018 and was discharged on 02/16/2018. There was documentation, as well as verification from facility staff, that the client's funding source was billed for services provided; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #10 was admitted on 12/19/2017 and was discharged on 12/28/2017. There was documentation, as well as verification from facility staff, that the client's funding source was billed for services provided; however, there was no proper consent to release information form signed by the client prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Social Workers obtained releases of information from all current patients on 4/30/18. The Admissions department added a release of information for the Funder to the admission packet and began obtaining consent for all incoming patients on 4/30/18. The Director of Admissions or designee is responsible to audit 50 randomly chosen records per month to ensure ongoing compliance. Results of audit will be presented to the Performance Improvement Committee on a monthly basis. |