INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28 - 29, 2012 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.
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Plan of Correction
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709.122(b)(5) LICENSURE Follow-up
709.122. Detoxification.
(b) 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 one of three psychiatric detoxication client records.
The findings include:
Eleven client records were reviewed on March 29, 2012. Six of the eleven client records reviewed were psychiatric detoxification client's, #1, 2, 3, 4, 5 and 6. Follow-up documentation was required in two of the six detoxification records, #5 and 6. Follow up was not documented in record, #6. Per the facility's policy follow-ups will be done within 7 days after discharge for clients who obtain a aftercare plan, 30 days and 90 days for all others. An interview with facility staff on March 29, 2012 confirmed the findings.
Client #6 was admitted on November 21, 2011 and discharged on November 22, 2011. The follow-up was due by December 22, 2012. As of the date of the inspection, there was no documentation of follow-up in client record #6.
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Plan of Correction
A weekly audit will be performed on all discharged clients due for 7-day, 30-day or 90-day follow-up. 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 client follow-ups. |
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 one of two psychiatric rehabilitation client records.
The findings include:
Eleven client records were reviewed on March 29, 2012. Follow-up documentation was required in two of the five client records, #10 and 11. Follow up was not documented in record, #11. Per the facility's policy, follow-up contacts will be completed within 7 days following discharge for clients who obtain a aftercare plan, 30 days and 90 days for all others. An interview with facility staff on March 29, 2012 confirmed the finding.
Client #11 was admitted on October 14, 2011 and discharged on November 11, 2011. The follow-up was due by December 11, 2011. As of the date of the inspection, there was no documentation of a follow-up contact in client record #11.
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Plan of Correction
A weekly audit will be performed on all discharged clients due for 7-day, 30-day or 90-day follow-up. 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 client follow-ups. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill record, the facility failed to prepare alternate exit routes during fire drills.
The findings include:
The fire drill record was reviewed on March 29, 2012. None of the fire drills conducted documented alternate exit routes used as the facility documented the main entrance as the primary exit used. The following months were reviewed; April 2011, May 2011, June 2011, July 2011, August 2011, September 2011, October 2011, November 2011, December 2011, January 2012, February 2012 and March 2012. An interview with facility staff on March 29, 2012 confirmed the findings.
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Plan of Correction
The Director of Plant Operations will prepare alternate exit routes during fire drills. The main exit will not be used for every fire drill. Alternate exit routes will be documented on the Fire Drill Form when utilized during a drill. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of client records, the facility failed to ensure that the consent to release forms were completed in accordance with the regulations in eight of eleven client records.
The findings include:
Eleven client records were reviewed on March 29, 2012. Eleven client records were required to have informed and voluntary consent forms. The consent to release forms must include the information to be released, the purpose of the release and whether or not the client was offered a copy of the release. Eight of the eleven did not have consent to release forms that were consistent with the regulations.
Client record #2 had two consent to release forms, dated March 28, 2012, that did not include documentation of the information that was being released.
Client record #3 had four consent to release forms, dated March 28, 2012 and March 29, 2012. The two release forms, dated on March 28, 2012, did not include the information that was being released. Additionally, one of the consent forms did not identify if the client had been offered a copy. Another consent form, March 29, 2012, did not document the purpose of the release.
Also, documentation in client record # 3, the facility exceeded 4 PA Code. 255.5 when information, client # 3's aftercare plan, was provided to a probation/parole officer.
Client record # 4 contained two consent to release forms, dated March 27, 2012, and one consent to release form, dated March 29, 2012. Two of the consents failed to document that the client was offered a copy of the consent to release forms. On another consent form, it was not documented what was being released, who the information was being released to, and whether the client was offered a copy of the consent.
Client record #5 contained three consent forms, dated January 3, 2012, that failed to document whether the client was offered a copy of the consent to release forms.
Client record #6 had one consent form, dated March 6, 2012, that failed to include the signatures of the client or witness on the consent to release form.
Client record #8 had two consent forms, dated March 28, 2012 and March 30, 2012, that did not document whether the client was offered a copy of the consent to release forms.
Client record #9 had two consent forms, dated March 9, 2012 and March 12, 2012. The consent form dated March 9, 2012 did not document whether the client was offered a copy of the consent to release forms. The consent form, dated March 12, 2012, did not document the information that was being released.
Client record #11 had two consent forms, dated October 14, 2011 and October 17, 2011. The consent form, dated October 14, 2012, failed to document the recipient of the information and the information that was being released. The consent form, dated October 17, 2011, did not document whether or not the client was offered a copy of the consent to release forms.
An interview with facility staff on March 29, 2012 confirmed the findings.
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Plan of Correction
All clinical staff will recieve training in confidentiality , as defined in the regulations, by the end of the third quarter of 2012.
All clinical staff will recieve training in the proper completion of a consent to release information in accordance with the regulations by the end of the third quarter, 2012.
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. The monitor will continue until 90% compliance achieved for three consecutive months. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based on a review of the physical plant inspection, the facility failed to ensure that food was not stored in a medication refrigerator.
The findings include:
The physical plant inspection took place on March 29, 2012. At approximately 10:20 am, it was observed that a refrigerator, designated by the facility to store medication, contained food items. An interview with facility staff on March 29, 2012 confirmed the findings.
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Plan of Correction
All nurses will be reminded of the regulation requiring no food in the medication refrigerators.
The Project Director will conduct monthly audits of the Medication rooms to ensure compliance with regulations regarding no food in the medication refrigerators.
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