INITIAL COMMENTS
|
This report is a result of an on-site licensure inspection conducted on September 18 - 19, 2013 by staff from the Division of Drug and Alcohol Program Licensure. 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.
|
Plan of Correction
|
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 the physical plant inspection and a review of the freezer temperature log, the facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The findings include:
The physical plant inspection was conducted on September 19, 2013 at approximately 10:30 AM. While en route to the kitchen, the Facility Director and House Manager informed the surveyor that the freezer was not working as of September 18, 2013.
The freezer's temperature log included documentation of two temperature readings on the following dates:
September 18, 2013: +22 degrees Fahrenheit and +23 degrees Fahrenheit
September 19, 2013: +29 degrees Fahrenheit and +24 degrees Fahrenheit
The Facility Director and Quality Assurance Director confirmed that the freezer's temperature exceeded 0 degrees Fahrenheit; however, they disputed the citation. They stated that the surveyor was aware that the freezer was not working properly and that the facility was in the process of having the freezer repaired. During the physical plant inspection an HVAC contractor was observed performing maintenance on the freezer.
This is a repeat citation. The facility was previously cited for non-compliance on 10/3/12.
|
Plan of Correction
In our Plan of Corrections for 2012, Horizon House indicated the following, "The House Manager/ supervisor and cook will conduct daily audits of the freezer temperature and record it in the freezer temperature log. Going forward, if the freezer measures over 0 degrees Fahrenheit a Work Order will be completed and submitted to the Horizon House Real Estate Department or external contractor for repairs on the same day with a follow-up phone call. The Program Director and the BHS County Director will ensure that the work is initiated by the end of business or the latest within 24 hours."
Unfortunately, our freezer malfunctioned the day prior to the 2013 inspection, and we followed our 2012 Plan of Correction by immediately hiring a contractor the same day. The Real Estate Department and subcontractor addressed and repaired the kitchen freezer beginning on September 19 through October 2 and the thermometer is now measuring 0 degree Fahrenheit. Part had to be imported from abroad to correct the problem.
Horizon House will continue to follow the above plan of corrections that was stipulated in 2012.
|
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of administrative documentation, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services by the end of the 2011/2012 fiscal year.
The findings include:
The project's fiscal year runs from July 1 through June 30.
On September 19, 2013, the project's administrative records were reviewed for a financial audit following the end of the 2011/2012 fiscal year. The financial audit was to be completed upon the conclusion of the fiscal year but was not completed until May 15, 2013.
The Facility Director and Behavioral Health Services Director confirmed the findings.
This is a repeat citation. The facility was previously cited for non-compliance on 10/3/12.
|
Plan of Correction
In order to ensure completion of the fiscal year 2012/2013 by December 31, 2013 as required, the organization has added additional resources in the Fiscal department to assist in the preparation of information required for audit completion. In addition, the commencement date of the 2012/2013 audit will begin earlier.
Implementation Date: December 31, 2013
Responsibility: Vice President, Finance
|
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent form for the disclosure of client information or failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 (b) in ten of ten client records.
The findings include:
Ten client records requiring documentation of informed and voluntary consent forms for the disclosure of client information were reviewed on September 18 - 19, 2013. The facility failed to obtain an informed and voluntary consent form for the release of client information or failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 (b) in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
The consent to release client information form for government agencies and third party payors contained in the ten client records reviewed allowed for the release of "medication records and any necessary information deemed required to treat." The disclosure of information permitted by the consent to release information forms exceeded the restrictions imposed at 4 Pa. Code 255.5 (b) for government agencies and third party payors.
The Facility Director confirmed the findings after reviewing the consent to release client information forms contained in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. It should be noted that by the end of the inspection, the Facility Director had updated/corrected the consent to release client information forms so that they complied with 4 Pa. Code 255.5 (b).
In addition, per progress notes contained in client record # 8, the client's mother participated in family counseling sessions and was consulted on the status of her son's treatment. However, the facility failed to obtain an informed and voluntary consent form for the release of client information from client # 8 for his mother.
The Facility Director reviewed record # 8 and confirmed the findings.
|
Plan of Correction
QI Director had updated/corrected the consent to release client information forms so that they complied with 4 Pa. Code 255.5 (b).
The Program staff were using outdated forms, and this was corrected the day of the inspection.
On October 9, 2013 the Susquehanna Park staff attended training on the HIPAA Regulations. The staff completed a sign?in sheet and completed training evaluations.
In our November 13, 2013 staff meeting we will review the policy and procedure on completing consent forms. The supervisors will reinforce confidentiality in their bi-weekly supervisions as well as the need to use updated forms.
The QI Manager and or the Program Director will conduct an independent clinical review monthly ensure that the most updated consents forms that adhere to the restrictions imposed by 4 Pa. Code 255.5 are used. Any deficiencies will be reviewed and discussed with the treatment team for immediate improvement.
|
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client records, the facility failed to ensure that physical examinations were completed upon admission in eight of ten client records.
The findings include:
Ten client records were reviewed for documentation of a physical examination on September 18 - 19, 2013. The facility failed to document physical examinations upon admission in client records # 1, 2, 4, 5, 6, 7, 8, and 10.
Client # 1 was admitted to the program on 7/8/13. The facility was required to document the physical exam at admission but it was not completed until 7/24/13.
Client # 2 was admitted to the program on 5/31/13. The facility was required to document the physical exam at admission but it was not completed until 6/18/13.
Client # 4 was admitted to the program on 4/16/13. The facility was required to document the physical exam at admission but it was not completed until 5/9/13.
Client # 5 was admitted to the program on 3/28/13. The facility was required to document the physical exam at admission but it was not completed until 4/15/13.
Client # 6 was admitted to the program on 1/31/13. The facility was required to document the physical exam at admission but it was not completed until 2/21/13.
Client # 7 was admitted to the program on 7/23/13. The facility documented a physical examination; however, it was not dated.
Client # 8 was admitted to the program on 5/7/13. The facility was required to document the physical exam at admission but it was not completed until 5/24/13.
Client # 10 was admitted to the program on 12/12/12. The facility was required to document the physical exam at admission but it was not completed until 12/29/12.
The Facility Director and Quality Assurance Director confirmed the findings.
|
Plan of Correction
We have made arrangements with Abbottsfalls Family Practice to complete the physical examinations upon a participant's admission. The nurse will coordinate the appointment with Abbottfalls to ensure the timeliness of the appointment.
Individuals who enter into treatment in a medically compromised state will be transported to the nearest hospital emergency room for immediate medical care.
The director will review all newly admitted participants' physical examination appointments during the daily morning meetings.
The QI Manager and the Program Director will review the health records of all new participants to ensure that the participants receives a physical exam within 7 days of admission. Staff who do not adhere to this 7-day physical exam requirement will have this discussed in their biweekly supervision with the Program Director until it is corrected for future admissions. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in five of ten client records.
The findings include:
Ten client records were reviewed on September 18 - 19, 2013. The facility failed to assure that individual counseling sessions were conducted in accordance with the individual treatment plan in client records # 1, 2, 3, 6 and 9.
Client # 1 was admitted on 7/8/13 and was still an active client on 9/18/13. The individual treatment plan documented on 7/10/13 prescribed weekly individual counseling sessions. The facility failed to conduct individual sessions in accordance with the treatment plan as no documentation of individual sessions was included in the client record.
Client # 2 was admitted on 5/31/13 and was still an active client on 9/18/13. The individual treatment plan documented on 6/4/13 prescribed weekly individual counseling sessions. The facility failed to conduct individual counseling sessions in accordance with the individual treatment plan. Individual counseling sessions were only documented for the following dates: 9/16/13, 8/15/13, 7/22/13, 7/15/13, 6/17/13 and 6/4/13.
Client # 3 was admitted on 5/4/13 and was still an active client on 9/18/13. The individual treatment plan documented on 5/29/14 prescribed weekly individual counseling sessions. The facility failed to conduct individual counseling sessions in accordance with the individual treatment plan. Individual counseling sessions were only documented for the following dates: 8/26/13, 7/26/13, 7/3/13, 6/23/13, 5/29/13, 5/23/13 and 5/16/13.
Client # 6 was admitted on 1/31/13 and was still an active client on 9/18/13. The individual treatment plan documented on 2/1/13 prescribed weekly individual counseling sessions. The facility failed to conduct individual counseling sessions in accordance with the individual treatment plan. Individual counseling sessions were only documented for the following dates: 9/16/13, 9/9/13, 8/16/13, 7/15/13, 7/2/13, 6/14/13, 5/29/13, 5/15/13, 4/15/13, 3/21/13, 3/14/13, 3/1/13, 2/29/13, 2/22/13, 2/14/13, 2/5/13 and 2/1/13.
Client # 9 was admitted on 4/29/13 and was discharged on 7/3/13. The individual treatment plan documented on 5/14/13 prescribed weekly individual counseling sessions. The facility failed to conduct individual counseling sessions in accordance with the individual treatment plan. Individual counseling sessions were only documented for the following dates: 6/14/13, 6/9/13, 5/14/13 and 5/1/13.
The Facility Director did not dispute the findings.
|
Plan of Correction
Director/ Supervisor has conducted weekly checks of all therapist's individual and group progress notes which started immediately after the inspection (on 9/20/13) to ensure that they are completed and fulfill the mandatory clinical hour requirements. This review will continue until the end of November to ensure compliance.
The supervisor will continue to review document on a monthly basis to determine whether or not the individual counseling sessions were conducted in accordance with the individual's recovery plan during the staff bi-weekly supervision. Any deficiencies will be reviewed and discussed with the treatment team for immediate improvement.
The QI Manager and the Program Director will conduct an independent clinical review monthly to assure that counseling services were provided and documented according to the individual treatment and rehabilitation.
|
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:
|
Observations
Based on a review of client records, the facility failed to verify that any work done by the client at the project is an integral part of the treatment and rehabilitation plan in ten of ten client records.
The findings include:
Ten client records requiring verification that work done by the client at the project was an integral part of the treatment and rehabilitation plan were reviewed on September 18 - 19, 2013. The facility failed to verify that work completed at the project by clients # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 was an integral part of the individual treatment and rehabilitation plan.
An interview with the Facility Director confirmed that clients # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 participated in work outside of cleaning their personal space and that verification of work as therapy had not been completed.
|
Plan of Correction
The Program Director signs off on all treatment plans upon completion before they are filed in the health record. Prior to signing the Initial Treatment Plan, the Program Director will review the plan to ensure that it incorporates any work therapy that the client is or will be doing as part of his treatment. If the plan does not include work therapy, the program director will return it to the staff for immediate correction before she signs and approves it. The Program Director will address any treatment plan issues with the D&A Specialist as the need arises as well as in biweekly supervision.
The QI Manager and the Program Director will conduct an independent clinical review monthly to ensure that any work that the participants complete is an integral part of their treatment planning. Any deficiencies will be reviewed and discussed with the treatment team for immediate improvement.
|