INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2019 through December 20, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to adhere to the project's policy and procedure on collecting feedback on completed trainings. Every completed training was missing a feedback form in each employee record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Google Form of the survey was created that contains all the necessary questions for feedback after completed trainings.
Staff are able to access the survey online via a link, and then fill out the feedback survey. After they hit the submit button, their form will live on Google's cloud server.
The Program Director can access these forms by following a private link they have stored. Once they access the main screen, they'll be able to see all the forms that have been completed by the staff, and can also print the forms or export the form results to an Excel document.
The Program Director will also be able to edit the form if necessary.
The Program Admin will ensure that each staff training has a corresponding evaluation form by saving both the proof of training and the training evaluation in the staff's training record. Any discrepancy will be immediately addressed by the Program Director. |
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
The facility failed to prepare and utilize alternate exit routes during every fire drill conducted from December 2018 to October 2019. The facility documented on their fire drill log that only the front door exit was used during the drills.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Effective immediately, the House Manager will be responsible for managing monthly fire drills. The House Manager will create a yearly calendar that will consist of the exit that should be used. The unannounced drills will be run monthly by the Residential Counselors or Certified Peer Specialist who will ensure that alternate exits are used for each drill. Quarterly the completed drills will be reviewed with the Facility Director to ensure that alternate exits are used. Any discrepancy will be immediately addressed by the Facility Director. |
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 personnel records contained documentation of an annual written individual staff performance evaluation in one of four applicable employee records reviewed.
Employee # 1 was hired as the Project Director on October 1, 2000. An annual written individual performance evaluation, signed by the reviewer on January 31, 2019, was incomplete and was not signed by the employee. Additionally, there was no documentation of an annual written individual performance evaluation completed for 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, HR will monitor the completion of the Project Director's annual performance evaluation, and ensure that it is signed by both the reviewer and the Project Director. The Human Resources Vice President will follow up if needed to ensure that the Project Director's annual performance evaluation is completed and signed by all applicable parties. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to include the specific information that was to be disclosed on a consent to release information form in two of seven client records.
Client # 2 was admitted on May 2, 2019 and was active at the time of the inspection. There was a consent to release information form to a funding source signed and dated by the client on May 2, 2019; however, the consent form did not include the specific information to be released.
Client # 5 was admitted on July 11, 2019 and discharged on October 22, 2019. There was a consent to release information form to a funding source signed and dated by the client on July 11, 2019; however, the consent form did not include the specific information to be released.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In the January 2020 staff meeting, Susquehanna Park staff will be re-trained by the Facility Director and Quality Improvement Specialist on how to properly complete consents forms. The Records Clerk will ensure that all consents are properly filled out before being filed. During monthly health record reviews, the QI Specialist will review the consents in the health record to ensure proper completion. Any discrepancy will be brought to the attention of the Facility Director who will immediately address it with the staff.
A new release for Client #2 was not obtained before the participant was discharged on January 1, 2020. The incomplete release will not be honored due to being incomplete and will be archived.
A new release of information for Client # 5 could not be obtained because they were discharged on October 22, 2019. The incomplete release will not be honored due to being incomplete and will be archived.
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709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on the consent form in one of seven client records.
Client # 1 was admitted on September 12, 2019 and was active at the time of the inspection. There was a consent to release information form to a urinalysis lab signed and dated by the client on September 12, 2019; however, the consent form did not include the purpose for the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In the January 2020 staff meeting, Susquehanna Park staff will be re-trained by the Facility Director and Quality Improvement Specialist on how to properly complete consents forms. The Records Clerk will ensure that all consents are properly filled out before being filed. During monthly health record reviews, the QI Specialist will review the consents in the health record to ensure proper completion. Any discrepancy will be brought to the attention of the Facility Director who will immediately address it with the staff.
On 1/13/2020 Client # 1 signed a new release of information form for the urinalysis lab including the purpose for the disclosure. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
The facility failed to maintain a complete client record on individuals, which is to include case consultation notes in three of seven client records.
Client # 1 was admitted on September 12, 2019 and was active at the time of the inspection.
Client # 3 was admitted on July 12, 2019 and was active at the time of the inspection.
Client # 7 was admitted on December 12, 2018 and was discharged on April 18, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Case Consultation will be organized by the designated D&A Specialist. A monthly calendar will be distributed in advance to the clinical team as well as supports to inform them of the Case Consultation schedule. During the meeting with the participant present, the Case Consultation/Team Meeting form will be completed and signed by all parties present. The designated D&A Specialist will check for form for completion and submit to the Record Clerks for filing in the health record. During monthly chart reviews from Horizon House Quality Department, the QI Specialist will ensure that forms are in the chart within the appropriate timeframe. Any discrepancy will immediately be addressed by the Program Director.
Client # 1 has an updated case consultation scheduled for January 23, 2020.
Client # 3 has an updated case consultation dated January 9, 2020.
Client # 7 could not have their case consultation issue rectified as they were discharged on April 18, 2019.
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