INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21 through March 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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 and a plan of correction is due on April 23, 2011.
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Plan of Correction
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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.
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Observations
Based on review of administrative materials and an interview with the Chief Compliance Officer, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative material was reviewed on March 21, 2011 through March 22, 2011.
The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility ' s 2009 through 2010 fiscal year ended on June 30, 2010. However, the facility's financial audit for this period was not completed until March 8, 2011.
An interview with the Chief Compliance Officer conducted on March 22, 2011 confirmed that the facility's financial audit for the facility's 2009 through 2010 fiscal year was not completed until March 8, 2011.
This is a repeat citation. The facility was cited on April 10, 2008 and on January 17, 2007 for a financial audit.
The facility ' s Plan of Corrections for the April 10, 2008 citation was as follows:
" Fiscal Audit is done at the behest of Chimes, Inc., our parent company. The Program Director will reemphasize with the audit firm the importance of completing the audit by the end of the calendar year. "
The facility ' s Plan of Corrections for the January 17, 2007 citation was as follows:
" Audit to be completed within six months of the end of the fiscal year. The Program Director will monitor compliance. "
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Plan of Correction
Holcomb Behavioral Health Systems will arrange an independent audit of our Substance Abuse programs by the end of the close of the fiscal year.
The Program Director will be responsible for compliance. HBHS will arrange for such an audit on an annual basis, so that the problem does not reoccur. |
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:
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Observations
Based on a review of client records and an interview with the Clinical Supervisor and Chief Compliance Officer, the facility documented consent to release information forms that allowed for the release of client information that exceeded which is permissible under 4 Pa. Code subsections 255.5 (b), in four of four client records reviewed.
The findings include:
On March 24, 2011, four records were reviewed for consent to release information forms. The facility documented consent to release information forms that allowed for the release of client information that exceeded which is permissible under 4 Pa. Code subsections 255.5 (b) in client records # 1, 2, 3, and 4.
Client record # 1
1. Two consents to release information to a government agency dated 9/15/10 were completed allowing the release of the discharge summary and treatment summary.
Client record # 2
1. Two consents to release information to an insurance company dated 1/6/11 were completed allowing the release of the treatment summary and discharge summary.
2. Two consents to release information to a government agency dated 1/6/11 were completed allowing the release of the treatment summary and discharge summary.
3. One consent to release information to a government agency dated 1/6/11 was completed allowing the release of the treatment summary.
Client record # 3
1. Two consents to release information to an insurance company dated 1/5/11 were completed allowing the release of the treatment summary and discharge summary.
Client record # 4
1. Two consents to release information to an insurance company dated 12/20/10 were completed allowing the release of the treatment summary and discharge summary.
An interview with the Clinical Supervisor and Chief Compliance Officer on March 24, 2011 confirmed that the consents to release information were completed allowing documented the release of client information that exceeded which is permitted under 4 Pa. Code subsections 255.5 (b) in client records # 1, 2, 3, and 4.
This is a repeat citation. The facility was cited on April 9, 2009; April 10, 2008; August 2, 2007; August 24, 2006; June 2, 2005; July 22, 2004; and July 25, 2003 for documenting the release of client information that exceeded which is permissible under 4 Pa. Code subsections 255.5.
The facility ' s Plan of Correction for the April 9, 2009 citation was as follows:
" Staff training held on April 20th; Confidentiality regulations were reviewed, and all charts purged of invalid consents. The charts will be monitored in an ongoing fashion by the Program Supervisor, and Facility Manager. "
The facility ' s Plan of Correction for the April 10, 2008 citation was as follows:
" Program Coordinator, Intake Counselor, and assistant Counselor all are schedule for Confidentiality Training 6-9-08, at Mirmont. The Program Director will be responsible for ensuring completion of this training. The specific Consent form referenced in the citation was updated correctly. The Clinical Supervisor will be responsible for ensuring that all future releases are filled out appropriately. This issue will be addressed during ongoing supervision."
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Plan of Correction
Holcomb's Chief Compliance Officer created a specific Release of Information form for all entities related to PA 255.5. This Release of Information, by its very structure limits the information that can be authorized for release by the client so that no information can be authorized for release beyond 255.5(b). The new form was disseminated to project staff the week of April 18, 2011. All hard copies of the old form were shredded. The new form will ensure clients do not consent to have information released beyond the information allowed in PA 255.5. All clients who signed the old form will be given the new form to sign no later than May 15, 2011. All newly admitted clients as of April 19, 2011 are given the new ROI with the 255.5 limitations. The Clinical Supervisor will conduct weekly chart reviews through May 20, 2011 to verify that only the new form is being utilized. After all charts are in compliance, the Clinical Supervisor will conduct ongoing, random chart reviews to ensure current and future compliance in utilization of the Release of Information in accordance with 4 Pa. Code subsections 255.5(b.) If the Clinical Supervisor discovers any violations, immediate remediation will be provided to each staff member as appropriate. Staff will receive quarterly reminders in staff meetings and/or trainings of the purpose and implication of being in compliance with Pa. 255.5(b)
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705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
Based on observation shortly after arriving at the facility and an interview with the Clinical Supervisor, the facility failed to provide a certificate of occupancy from the Department of Labor and Industry for Holcomb Associates building located at 225 South 69th Street.
The findings include:
On March 24, 2011 at approximately 8:30 A.M., it was observed that the facility lacked a posted certificate of occupancy from the Department of Labor and Industry for Holcomb Associates building located at 225 South 69th Street. The Clinical Supervisor was able to produce Certificates of Occupancy for Holcomb Associates building located at 225 South 69th Street from the local municipality; however, the Certificates of Occupancy predated the 2004 opt-in date for local municipalities conducting their own inspections. The opt-in date for the township where the facility is located was 6/16/2004.
When asked about the Certificates of Occupancy for the building, the Clinical Supervisor stated that the facility had no additional documentation other than the Certificates of Occupancy she presented provided by the local municipality as of March 24, 2011.
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Plan of Correction
The facility located the original L & I CO and forwarded a copy to DAPL and the original is prominently displayed in the lobby. Facility staff will ensure that during all future inspections the Licensing Specialist is shown the appropriate Certificate of Occupancy. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observation upon arriving at the facility on March 24, 2011 and an interview with the Clinical Supervisor, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
Upon arriving at the facility it was observed at 7:57 A.M. that the facility had one dumpster located in the facility's parking lot. The dumpster was only partially covered with lids.
An interview with the Clinical Supervisor conducted on March 24, 2011 confirmed that the dumpster was only partially covered with lids.
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Plan of Correction
The dumpster in question was closed immediately after DAPL Staff pointed it out to us, by the Facility Director. Holcomb has for years had weekly trash removal; the last removal was Tuesday, 4-12-11, and the trash will be removed every Tuesday therafter.
Two assigned staff members will inspect the dumpster on a daily basis to ensure that the dumpster is fully covered with lids. This Process will be monitored by our facility Environment of Care Specialist. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the inspection of the physical plant and an interview with the Clinical Supervisor, the facility failed to ensure that heaters that are not permanently mounted or installed were not permitted in the facility.
The findings include:
An inspection of the physical plant was conducted on March 24, 2011. During the inspection, at 8:34 A.M., it was observed that there was a portable space heater located in an individual counseling office, room # 5 on the first floor.
An interview with the Clinical Supervisor conducted on March 24, 2011 confirmed that that individual counseling office room # 5 on the first floor had a portable space heater.
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Plan of Correction
The space heater mentioned in this citation was removed from the building the morning of 3-24-11. As a matter of policy, Holcomb Behavioral Health Systems does not permit portable space heaters in it's facilities. The offices will now be inspected on a weekly basis to ensure staff compliance on this issue.
HBHS's Environment of Care Representative will be responsible for office inspection, to ensure compliance;
This person reports to HBHS's Environment of Care Director, who monitors such inspections. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, staffing requirements facility summary report, and an interview with the Human Resource Specialist and Chief Compliance Officer, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of seven records reviewed.
The findings include:
On March 22, 2011, seven personnel records were reviewed to verify that staff had received the required training hours. The facility failed to document the required training hours in personnel record # 7.
Employee # 7, the Medical Director, was hired in May 1995, HIV/AIDS training was due in May 1997. However, personnel record # 7 did not include documentation of HIV/AIDS training as of March 22, 2011.
An interview with the Human Resource Specialist and Chief Compliance Officer conducted on March 22, 2011 confirmed that personnel record # 7 did not include documentation of HIV/AIDS training.
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Plan of Correction
Holcomb Behavioral Health Systems will ensure that our Chief Medical Officer will have the minimum 6 hours of HIV/AIDS training no later than June 30, 2011.
The Facility Director will locate an appropriate DOH approved HIV/AIDS training, and facilitate attendance.
If, in the future, HBHS hires a new Medical Director who also graduated Medical School before 3-94, we will arrange attendance at the HIV/AIDS training within two years. |