D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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HORSHAM CLINIC
722 EAST BUTLER PIKE
AMBLER, PA 19002

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Survey conducted on 09/22/2008

INITIAL COMMENTS
This report is a result of an on-site complaint investigation conducted on September 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, the allegations made Horsham Clinic were partially substantiated and a plan of correction is due on November 12, 2008.	Plan of Correction
704.12(a)(1)(i) LICENSURE Client/couns ratios 704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios. (a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client. (1) Inpatient nonhospital detoxification (residential detoxification). (i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
Observations Based upon a review of the facility ' s Daily Census Summary Reports and the facility staffing schedules for the the evening and night shifts during the months of August and September 2008 ,the facility failed to ensure that there was one primary care staff person for every seven clients. Findings: The facility failed to maintain a ratio of one primary care staff person for every seven clients on the evening and night shifts throughout the month of August and from September 1 through 22, 2008 as indicated below: August 1, 2008 inpatient census 39 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 August 2, 2008 inpatient census 41 Evening Primary Care Staff 5 Night Shift Primary Care Staff 1 August 3, 2008 inpatient census 49 Evening Primary Care Staff 4 Night Shift Primary Care Staff 1 August 4, 2008 inpatient census 50 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 August 5, 2008 inpatient census 52 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 August 6, 2008 inpatient census 52 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 August 7, 2008 inpatient census 45 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 August 8, 2008 inpatient census 42 Evening Primary Care Staff 3 Night Shift Primary Care Staff 0 August 9, 2008 inpatient census 52 Evening Primary Care Staff 2 Night Shift Primary Care Staff 1 August 10, 2008 inpatient census 56 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 August 11, 2008 inpatient census 55 Evening Primary Care Staff 4 Night Shift Primary Care Staff 2 August 12, 2008 inpatient census 55 Evening Primary Care Staff 4 Night Shift Primary Care Staff 2 August 13, 2008 inpatient census 55 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 August 14, 2008 inpatient census 53 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 August 15, 2008 inpatient census 52 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 August 16, 2008 inpatient census 53 Evening Primary Care Staff 4 Night Shift Primary Care Staff 1 August 17, 2008 inpatient census 56 Evening Primary Care Staff 4 Night Shift Primary Care Staff 2 August 18, 2008 inpatient census 56 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 August 19, 2008 inpatient census 53 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 August 20, 2008 inpatient census 51 Evening Primary Care Staff 4 Night Shift Primary Care Staff 1 August 21, 2008 inpatient census 51 Evening Primary Care Staff 4 Night Shift Primary Care Staff 2 August 22, 2008 inpatient census 51 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 August 23, 2008 inpatient census 54 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 August 24, 2008 inpatient census 56 Evening Primary Care Staff 2 Night Shift Primary Care Staff 2 August 25, 2008 inpatient census 54 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 August 26, 2008 inpatient census 52 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 August 27, 2008 inpatient census 53 Evening Primary Care Staff 2 Night Shift Primary Care Staff 1 August 28, 2008 inpatient census 51 Evening Primary Care Staff 2 Night Shift Primary Care Staff 1 August 29, 2008 inpatient census 45 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 August 30, 2008 inpatient census 47 Evening Primary Care Staff 4 Night Shift Primary Care Staff 1 August 31, 2008 inpatient census 54 Evening Primary Care Staff 4 Night Shift Primary Care Staff 2 September 1, 2008 inpatient census 55 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 September 2, 2008 inpatient census 52 Evening Primary Care Staff 4 Night Shift Primary Care Staff 2 September 3, 2008 inpatient census 50 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 September 4, 2008 inpatient census 50 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 September 5, 2008 inpatient census 50 Evening Primary Care Staff 2 Night Shift Primary Care Staff 1 September 6, 2008 inpatient census 55 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 September 7, 2008 inpatient census 56 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 September 8, 2008 inpatient census 54 Evening Primary Care Staff 2 Night Shift Primary Care Staff 2 September 9, 2008 inpatient census 54 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 September 10, 2008 inpatient census 54 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 September 11, 2008 inpatient census 52 Evening Primary Care Staff 2 Night Shift Primary Care Staff 2 September 12, 2008 inpatient census 47 Evening Primary Care Staff 4 Night Shift Primary Care Staff 2 September 13, 2008 inpatient census 56 Evening Primary Care Staff 5 Night Shift Primary Care Staff 1 September 14, 2008 inpatient census 56 Evening Primary Care Staff 4 Night Shift Primary Care Staff 1 September 15, 2008 inpatient census 55 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 September 16, 2008 inpatient census 54 Evening Primary Care Staff 4 Night Shift Primary Care Staff 1 September 17, 2008 inpatient census 54 Evening Primary Care Staff 3 Night Shift Primary Care Staff 2 September 18, 2008 inpatient census 48 Evening Primary Care Staff 3 Night Shift Primary Care Staff 1 September 19, 2008 inpatient census 39 Evening Primary Care Staff 2 Night Shift Primary Care Staff 0 September 20, 2008 inpatient census 43 Evening Primary Care Staff 2 Night Shift Primary Care Staff 2 September 21, 2008 inpatient census 50 Evening Primary Care Staff 2 Night Shift Primary Care Staff 2 September 22, 2008 inpatient census 56. Evening Primary Care Staff 4 Night Shift Primary Care Staff 2	Plan of Correction This facility does not file electronically, a Plan of Correction is on file with the Department of Health.
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction 709.14. Restriction on license. (b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions: (5) Change in authorized maximum capacity.
Observations Based upon a review of the facility ' s Daily Census Summary Reports for the months of August and September 2008, a physical count of the beds and a review of the daily census board on the two units licensed by the Department, all occurring on September 22, 2008, it was determined the facility had exceeded their licensed capacity of 50 on 23 days during the month of August and 14 days during the month of September, 2008. Findings: Based upon the Daily Census Summary Report for the month of August the facility exceeded their licensed capacity of 50 beds on the following 23 days: August 5, 2008 inpatient census 52 August 6, 2008 inpatient census 52 August 9, 2008 inpatient census 52 August 10, 2008 inpatient census 56 August 11, 2008 inpatient census 55 August 12, 2008 inpatient census 55 August 13, 2008 inpatient census 55 August 14, 2008 inpatient census 53 August 15, 2008 inpatient census 52 August 16, 2008 inpatient census 53 August 17, 2008 inpatient census 56 August 18, 2008 inpatient census 56 August 19, 2008 inpatient census 53 August 20, 2008 inpatient census 51 August 21, 2008 inpatient census 51 August 22, 2008 inpatient census 51 August 23, 2008 inpatient census 54 August 24, 2008 inpatient census 56 August 25, 2008 inpatient census 54 August 26, 2008 inpatient census 52 August 27, 2008 inpatient census 53 August 28, 2008 inpatient census 51 August 31, 2008 inpatient census 54 Based upon the Daily Census Summary Report for the month of September and a physical bed count on September 22, 2008 the facility exceeded their licensed capacity of 50 beds on the following 14 days: September 1, 2008 inpatient census 55 September 2, 2008 inpatient census 52 September 6, 2008 inpatient census 55 September 7, 2008 inpatient census 56 September 8, 2008 inpatient census 54 September 9, 2008 inpatient census 54 September 10, 2008 inpatient census 54 September 11, 2008 inpatient census 52 September 13, 2008 inpatient census 56 September 14, 2008 inpatient census 56 September 15, 2008 inpatient census 55 September 16, 2008 inpatient census 54 September 17, 2008 inpatient census 54 September 22, 2008 inpatient census 56	Plan of Correction This facility does not file electronically, a Plan of Correction is on file with the Department of Health.