INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 2-3, 2012 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
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel training records and a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor receive at least 25 clock hours of training annually.
The findings include:
According to the Staffing Requirements Facility Summary Report, the facility training year runs from January 1, 2011 to December 31, 2011.
Two counselors' records were reviewed for training hours on October 2, 2012. One out of two records did not document 25 clock hours of training for the 2011 training year, specifically employee #4.
Employee # 4 was hired as a counselor on September 15, 2008. Employee # 4 had only 14.75 documented clock hours of training during January 1, 2011 through December 31, 2011.
On October 2, 2012 an interview was held with the Facility Director in which an inquiry was made if employee #4 had any additional documentation of training hours for the 2011 training year, the inspector was advised there were no additional documented hours for employee #4.
This is a repeat deficiency. The facility was previously cited for noncompliance on 10/18/2011.
|
Plan of Correction
Employee #4 has already completed his required 25 hours for January 2012 through December 2012 training year. Going forward, the Director/ Supervisor will conduct quarterly checks of all staff training reports to ensure that they attend and fulfill the mandatory 25 hours training requirements. Additionally, the annual individual staff training plan will be reviewed with each employee at least quarterly. The supervisor will continue to include and document training requirements in supervision with each staff on a monthly basis.
The QI Manager will send quarterly reminders to the program director starting in November 2012 to ensure that the 25-hour training requirements are being met. Additionally, in conjunction with the Program Director, the QI Manager will also conduct semi-annual reconciliation of training records for all D&A staff to ensure that they are meeting the requirements.
|
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 an inspection of the physical plant and review of the facility's refrigerator/freezer temperature log, the facility failed to provide documentation that frozen food is kept at or below 0 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on October 3, 2012. At approximately 1:15 PM the thermometer in freezer #1 read 15 degrees Fahrenheit during the inspection.
The facility's refrigerator/freezer temperature log was reviewed for the time period covering September 1, 2012 to October 2, 2012. The freezer measured over 0 degrees Fahrenheit each day during the time period reviewed.
The findings were confirmed by the Facility Director and Real Estate staff during the inspection.
|
Plan of Correction
The House Manager/Supervisor has provided the cook with the Safe Serve Certification Manual to review. The House Manager/Supervisor will follow-up by the end of November 2012 to review the manual with the cook.
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 completed by the end of business or the latest within 24 hours.
The Real Estate Department and subcontractor addressed and repaired the kitchen freezer on October 24, 2012, and the thermometer is now measuring 0 degree Fahrenheit.
Starting November 12, 2012, the Program Director will review the log weekly for one month and then on a monthly basis to ensure that proper procedures are being followed when the freezer reading is above 0 degree Fahrenheit.
|
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
Based on a physical plant inspection the facility failed to ensure that stairways, hallways and exits from rooms and the residential facility were unobstructed.
The findings include:
A physical plant inspection was conducted on October 3, 2012. At approximately 1:56 PM, it was found that the emergency exits from the first, second, and third floors discharge into the courtyard which is padlocked and does not allow for immediate access to the street in the case of an emergency.
The findings were confirmed by the Facility Director and Real Estate staff during the inspection.
|
Plan of Correction
The House Manager completed a work order to have the Horizon House Real Estate Department removed the hasp and padlock from the courtyard gate and replace it with a deadbolt and latch. The work was completed on 10/05/12. The photograph of the new lock was emailed to the D&A Licensing Specialist at Department of Health.
The House Manager will continue to conduct weekly rounds to ensure that the gate will have unobstructed access in the event of emergencies. Starting 11/12/12, the weekly checks will be documented on the Weekly Facility Checklist, and a work order will be completed immediately for any related issues.
|
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 upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Administrative documents were reviewed on October 2, 2012. Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit for the 2010-2011 year was late as it was completed April 27, 2012.
The findings were reviewed during the exit interview.
|
Plan of Correction
The SCAs that fund Horizon House are part of the Federal Single Audit ACT, and over the next two weeks Horizon House will be submitting a waiver (to DDAPL) to extend the completion timeframe of the fiscal audit. The waiver will be accompanied by appropriate evidence that the SCAs are participants of the Federal Single Audit ACT. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services in four of five client records.
The findings include:
Five client records were reviewed for treatment plans on October 3, 2012. Five out of five client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 1, 2, 3, 4 and 5.
Client #1 was admitted to treatment on July 6, 2012. The treatment plan was completed on July 23, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client #2 was admitted to treatment on July 25, 2012. The treatment plan was completed on August 9, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client #3 was admitted to treatment on July 25, 2012. The treatment plan was completed on August 9, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client #4 was admitted to treatment on July 16, 2012 and discharged on September 14, 2012. The treatment plan was completed on August 1, 2012 and did not include the type and frequency of treatment and rehabilitation services
Client #5 was admitted to treatment on December 27, 2011 and discharged on May 3, 2012. The treatment plan was completed on January 6, 2012 and did not include the type and frequency of treatment and rehabilitation services.
The findings were discussed with the facility director, quality assurance staff, and clinical staff during the exit interview.
|
Plan of Correction
The Treatment Plan template was revised in November 2012 to include the type and frequency of treatment and rehabilitation services. The Program Director signs off on all treatment plans (initial plan, comprehensive plan and 30-day updates) upon completion before they are filed in the health record. Prior to signing each treatment plan, the Program Director will review the plan to ensure that it is completed in its entirety. If the plan is incomplete, 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 or the Program Director will conduct an independent clinical review weekly for the first 2 months and monthly thereafter to ensure that the treatment plans are completed thoroughly. Any deficiencies will be reviewed and discussed with the treatment team for immediate improvement.
|
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
|
Observations
Based on a review of client records, the facility failed to document a complete chronological listing of the various specific services provided to each individual.
The findings include:
Five inpatient records were reviewed for documentation of a record of service on October 2, 2012. The facility failed to document services as provided to the clients in two out of five client records, specifically #'s 4 and 5.
Client #4 was admitted to treatment on July 16, 2012 and discharged on September 14, 2012. There was no documentation of a record of service for any group notes in the chart representing client #4.
Client #5 was admitted to treatment on December 27, 2012 and discharged on May 3, 2012. There was no documentation of a record of service for any group notes in the chart representing client #5.
The findings were confirmed with the facility director during the chart review. The findings were not disputed.
|
Plan of Correction
The program director will conduct biweekly supervision with the Records Clerk which will include a review of the Record of Service. The Records Clerk was retrained by the program director on 10/31/12 on how to correctly document the groups on the Record of Service. Starting on 11/12/12, the program director will review a sample of the charts weekly for one month to ensure that the Record of Service is being completed for all groups. Once the Records of Service are being completed in a timely manner, the records will be reviewed monthly to ensure compliance. Monthly audit of charts by both the program director and QI Manager will ensure compliance with this plan. |