INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 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 Horizon House, Inc. 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to demonstrate sufficient coverage of staff certified in CPR and First Aid training during the 11:00 P.M. to 7:00 A.M. shift on the following dates:
October 16, 2018
October 18, 2018
October 23, 2018
October 25, 2018
October 30, 2018
November 1, 2018
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
Going forward, the supervisors will check the training histories of individuals before scheduling them for shifts to ensure there is sufficient coverage of staff trained in CPR and First Aid on each shift.
For temporary staff, the supervisors will communicate with Staffing Agencies prior to the start of an individual's employment service to ensure that the temp agency fulfills their contractual obligation to provide only temporary employees who are in compliance with required trainings.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that one personnel record contained documentation of an annual written individual performance evaluation. Employee # 1 was hired as the Project Director on October 1, 2000. There was no documentation of an annual written individual performance evaluation completed for the current review year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, who is the President/CEO of Horizon House, will work with the Board of Directors to obtain an annual performance evaluation.
Going forward, the Executive Assistant will monitor to ensure that the CEO receives an annual performance evaluation by the Board of Directors. The current year's performance evaluation will be completed by 1/31/19, since the next Board Meeting is in January 2019."
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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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed. Additionally, three of seven client records had consent to release information forms that were missing certain required elements.
Client # 1 was admitted on March 9, 2018 and was active at the time of the inspection. There was documentation of staff sending a 66-page fax to an individual; however, there was no consent to release information form on file prior to disclosure. Additionally, there was a consent form to a pharmacy signed by the witness on May 3, 2018 and a consent form to a dental provider signed by the witness on May 13, 2018; however, both consent forms were missing dated client signatures.
Client # 3 was admitted on May 4, 2018 and was active at the time of the inspection. There were two consent to release information forms to a pharmacy and urinalysis laboratory signed by the client on May 4, 2018; however, both consent forms were missing dated witness signatures.
Client # 7 was admitted on May 8, 2018 and was discharged on October 4, 2018. There was a consent to release information form to a urinalysis laboratory signed and dated by the client on May 18, 2018; however, the consent form was missing a dated witness signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On October 10, 2018, the Susquehanna Park staff attended training on the HIPAA regulations. The staff completed a sign-in sheet and training evaluations.
The QI Department will provide additional training to all staff in the next staff meeting on 12/12/18 to address the correct completion of Releases of Information including all required elements.
The supervisors will reinforce confidentiality requirements in their individual supervision with all staff as well as the need for staff to complete the release form in its entirety.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to document that the individual treatment and rehabilitation plans were developed with the client in three of seven client records.
Client #2 was admitted on June 20, 2018 and was active at the time of the inspection. The comprehensive treatment plan dated June 21, 2018 did not contain a client signature.
Client # 4 was admitted on April 30, 2018 and was discharged on September 30, 2018. The comprehensive treatment plan dated June 27, 2018 did not contain a client signature.
Client # 7 was admitted on May 8, 2018 and was discharged on October 4, 2018. There was no comprehensive treatment plan in the record at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will meet with each clinical staff during individual supervision to review all required documentation as it is due.
The Program Director will meet with the Supervisor during individual supervision to ensure that the clinical records are complete.
A new Program Director will be starting on 12/10/18. Starting in December, the Program Director/Supervisor will review documents on a monthly basis to determine whether the clinical records are complete.
Any deficiencies will be reviewed and discussed with the treatment team for immediate improvement.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in four of seven client records reviewed.
Client #2 was admitted on June 20, 2018 and was active at the time of the inspection. The comprehensive treatment plan was completed on June 21, 2018 and the next update was due no later than July 21, 2018. However, the update was not completed until August 23, 2018.
Client #3 was admitted on May 4, 2018 and was active at the time of the inspection. A treatment plan update was completed on June 20, 2018 and an update was due no later than July 20, 2016. However, the update was not completed until August 28, 2018.
Client #4 was admitted on April 30, 2018 and was discharged on September 30, 2018. The comprehensive treatment plan was completed on June 27, 2018 and an update was due no later than July 27, 2018. However, the update was not completed until August 27, 2018.
Client #6 was admitted on December 20, 2017 and was discharged on April 5, 2018. The comprehensive treatment plan was completed on January 25, 2018 and the next update was due no later than February 25, 2018. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will meet with each clinical staff during individual supervision to review all required documentation as it is due.
The Program Director will meet with the Supervisor during individual supervision to ensure that the clinical records are complete.
A new Program Director will be starting on 12/10/18. Starting in December, the Program Director/Supervisor will review documents on a monthly basis to determine whether the clinical records are complete.
Any deficiencies will be reviewed and discussed with the treatment team for immediate improvement.
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709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) 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:
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Observations
The facility failed to provide a complete client record in three of seven client records.
Client #4 was admitted on April 30, 2018 and was discharged on September 30, 2018. The record was missing documentation of follow-up information.
Client #6 was admitted on December 20, 2017 and was discharged on April 5, 2018. The record was missing documentation of follow-up information.
Client #7 was admitted on May 8, 2018 and was discharged on October 4, 2018. The record was missing documentation of a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will meet with each clinical staff during individual supervision to review all required documentation as it is due.
The Program Director will meet with the Supervisor during individual supervision to ensure that the clinical records are complete.
A new Program Director will be starting on 12/10/18. Starting in December, the Program Director/Supervisor will review documents on a monthly basis to determine whether the clinical records are complete.
Any deficiencies will be reviewed and discussed with the treatment team for immediate improvement.
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