INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Ocotober 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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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, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of one applicable personnel record reviewed.
Employee #3 was hired as a counselor on April 11, 2022 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than April 11, 2023; however, there was no documentation of completion of TB/STD training at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All Staff will receive Horizon House Training Plan that will be monitored monthly by Clinical Supervisor and Director who will ensure that all staff persons receive and document a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD.
The Program Director will have the Training Department run a quarterly training report to ensure that staff are receiving the required training within the required timeframe.
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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
Based on a review of personnel records, the facility failed to ensure that a sufficient number of staff persons were trained in CPR and first aid during the facility's hours of operation. The facility's hours of operation are 24/7. The facility failed to provide documentation that an employee was CPR certified during the following review period:
1, 2023, from 11PM to 7AM.
7, 2023, from 11PM to 7AM.
9, 2023, from 11PM to 7AM.
23, 2023, from 11PM to 7AM.
10 - 11, 2023, from 11PM to 7AM.
13, 2023, from 11PM to 7AM.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Clinical Supervisor and Director will ensure that a sufficient number of staff persons are trained in CPR and First Aid to cover all of the facility's hours of operation (24/7).
The Program Director will have the Training Department run a quarterly training report to ensure that majority of the staff received CPR and First Aid training.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
The 2nd floor community bathroom had two showers that did not have a slip-resistant surfaces.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/8/23 slip-resistant surfaces were provided in all showers, including the 2nd floor community bathroom.
On a monthly basis, the Site Manager will conduct a Site Residential Checklist to ensure that all bathtubs and showers have slip-resistant surfaces. This will be reviewed by the Program Director to ensure that all bathtubs and showers in need of attention are addressed.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The 1st floor community bathroom had a broken door entry handle.
The 2nd floor community bathroom had a shower with what appeared to be mold or mildew and dirt or grime at the floor of the shower. The shower had crack tiles in the floor of the shower stall.
The 3rd floor community bathroom had a shower with what appeared to be mold or mildew and dirt or grime at the floor of the shower.
This is a repeat citation from the November 17, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/16/23 the door handle was replaced with a new fully operational and locking door handle.
On 10/23/23 the 2nd floor bathroom was extensively cleaned and all mold or mildew and dirt or grime was removed. The bathroom will remain clean and during the physical plant inspection done by the house manager it will be checked monthly.
A work order has gone in to replace any and all cracked tile. The cracked tiles were replaced on 11/8/23.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of the facility ' s November 2022 through September 2023 fire drill log, the facility failed to conduct unannounced fire drills for the months of November 2022 through May 2023, August 2023, and September 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting in November 2023, fire drills will be documented monthly. November's fire drill was done on 11/8/23.
On a monthly basis, Quality Improvement Staff will conduct monthly site visits, and check the Fire Drill Binder to ensure that the fire drills are being conducted monthly. Any discrepancy will be reported to the Program Director who will promptly address it.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the November 2022 through September 2023 fire drill logs, the facility failed to identify, on the fire drill log, the amount of time it took for evacuation, the number of persons in the facility at the time of the drill, exit route used, and whether the fire alarm or a smoke detector was operative during each fire drill conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill form captures the documented fire drills including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
On a monthly basis, Quality Improvement Staff will conduct monthly site visits, and check the Fire Drill Binder to ensure that the fire drills forms are completely filled each month. Any discrepancy will be reported to the Program Director who will promptly address it.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the written client follow-up policy in three of three applicable client records reviewed.
The facility ' s policy and procedure manual stated that the emergency contact will be notified within 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client #4 was admitted on February 20, 2023 and was discharged against medical advice on March 12, 2023. There was no documentation, in the client record, that the emergency contact was notified at the time of inspection.
Client #5 was admitted on December 16, 2022 and was discharged against medical advice on February 27, 2023. There was no documentation, in the client record, that the emergency contact was notified at the time of inspection.
Client #7 was admitted on April 18, 2023 and was discharged against medical advice on April 21, 2023. There was no documentation, in the client record, that the emergency contact was notified at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and Director will monitor and train all staff on every shift for the emergency contact to be notified within 12 hours after a client is discharged from the facility against medical advice.
The Program Director and QI will conduct monthly checks of AFA/AMA incidents reports to ensure that there is a corresponding notes documenting the notification that was made to the emergency contact.
Any discrepancies will be addressed with staff by the Program Director.
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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
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed.
Client #1 was admitted on January 30, 2023 and was active at the time of inspection. There was documentation of urinalysis results, in the client record, dated July 21, 2023, August 29, 2023, and September 6, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #5 was admitted on December 16, 2022 and was discharged on February 27, 2023. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director shall obtain a written informed and voluntary consent from the client for the disclosure of information at intake and ongoing as needed. Staff will be reminded in annual Confidentiality Training that information should only be disclosed if there's an informed consent.
Program Director and the QI Specialist will conduct regular health record reviews to ensure staff are adhering to this requirement.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made on informed and voluntary consent to release information forms in one of seven client records reviewed.
Client #1 was admitted on January 30, 2023 and was active at the time of inspection. There was a release of information form that was signed and dated by the client on January 30, 2023; however, the form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
This is a repeat citation from the October 9, 2020, November 10, 2021, and November 17, 2022 licensing inspections.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor and Program Director shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent will be in writing and include, but not be limited to the name of the person or agency or organization to whom disclosure is made.
Staff will be reminded in annual Confidentiality Trainings that the consent form must be completely filled out.
Program Director and the QI Specialist will conduct regular health record reviews to ensure staff are adhering to this requirement.
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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
Based on a review of client records, the facility failed to document the specific information to be released on consent forms in six of seven client records reviewed.
Client #1 was admitted on January 30, 2023 and was active at the time of inspection. There were release of information forms to two people and the funding source that were signed and dated by the client on January 30, 2023; however, the specific information to be disclosed was not documented.
Client #2 was admitted on March 3, 2023 and was active at the time of inspection. There were release of information forms to two treatment providers, funding source, urinalysis laboratory, and medical provider that were signed and dated by the client on March 3, 2023; however, the specific information to be disclosed was not documented.
Client #3 was admitted on March 15, 2023 and was active at the time of inspection. There were release of information forms to a treatment provider, funding source, urinalysis laboratory, and transportation service that were signed and dated by the client on March 15, 2023; however, the specific information to be disclosed was not documented.
Client #4 was admitted on February 20, 2023 and was discharged on March 12, 2023. There were release of information forms to a urinalysis laboratory, transportation service, and pharmacy that were signed and dated by the client on February 20, 2023; however, the specific information to be disclosed was not documented.
Client #5 was admitted on December 16, 2022 and was discharged on February 27, 2023. There were release of information forms to a urinalysis laboratory and medical provider that were signed and dated by the client on December 16, 2022; however, the specific information to be disclosed was not documented.
Client #6 was admitted on April 27, 2023 and was discharged on August 17, 2023. There was a release of information form to probation and parole that was signed and dated by the client on April 27, 2023; however, the specific information to be disclosed was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent will be in writing and include, but not be limited to specific information disclosed.
Staff will be reminded in annual Confidentiality Trainings that the consent form must be completely filled out.
Program Director and the QI Specialist will conduct regular health record reviews to ensure staff are adhering to this requirement.
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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
Based on a review of client records, the facility failed to document the purpose of disclosure on consent forms in all client records reviewed.
Client #1 was admitted on January 30, 2023 and active at the time of inspection. There were release of information forms to two people, probation and parole, and funding source that were signed and date by the client on January 30, 2023; however, the purpose of the disclosure was not documented. Additionally, there was a release of information form to a physician that was signed and dated by the client on March 14, 2023; however, the purpose of the disclosure was not documented.
Client #2 was admitted on March 3, 2023 and was active at the time of inspection. There were release of information forms to a treatment provider, funding source, urinalysis laboratory, and medical provider that were signed and dated by the client on March 3, 2023; however, the purpose of the disclosure was not documented.
Client #3 was admitted on March 15, 2023 and was active at the time of inspection. There were release of information forms to a treatment provider, funding source, urinalysis laboratory, mental health provider and transportation service that were signed and dated by the client on March 15, 2023; however, the purpose of the disclosure was not documented.
Client #4 was admitted on February 20, 2023 and was discharged on March 12, 2023. There were release of information forms to a urinalysis laboratory, transportation service, emergency contact, funding source, a person and pharmacy that were signed and dated by the client on February 20, 2023; however, the purpose of the disclosure was not documented.
Client #5 was admitted on December 16, 2022 and was discharged on February 27, 2023. There were release of information forms to a urinalysis laboratory and medical provider that were signed and dated by the client on December 16, 2022; however, the purpose of the disclosure was not documented.
Client #6 was admitted on April 27, 2023 and was discharged on August 17, 2023. There were release of information forms to the funding source, two people, treatment provider, case manager, and mental health provider that were signed and dated by the client on April 27, 2023; however, the purpose of the disclosure was not documented.
Client #7 was admitted on April 18, 2023 and was discharged on April 21, 2023. There were release of information forms to the funding source, urinalysis laboratory, treatment provider, mental health provider, and emergency contact that were signed and dated by the client on April 18, 2023; however, the purpose of the disclosure was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent will be in writing and include, but not be limited to the purpose of disclosure.
Staff will be reminded in annual Confidentiality Trainings that the consent form must be completely filled out.
Program Director and the QI Specialist will conduct regular health record reviews to ensure staff are adhering to this requirement.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent form was offered to the client in five of seven client records reviewed.
Client #1 was admitted on January 30, 2023 and active at the time of inspection. There were release of information forms to two people, probation and parole, and funding source that were signed and date by the client on January 30, 2023; however, there was no documentation that indicated a copy of the consent forms were offered to the client. Additionally, there was a release of information form to a physician that was signed and dated by the client on March 14, 2023; however, there was no documentation that indicated a copy of the consent form was offered to the client. Additionally, there was a release of information form to a mental health provider that was signed and dated by the client on July 12, 2023; however, there was no documentation that indicated a copy of the consent form was offered to the client.
Client #2 was admitted on March 3, 2023 and was active at the time of inspection. There were release of information forms to a treatment provider, funding source, urinalysis laboratory, and medical provider that were signed and dated by the client on March 3, 2023; however, there was no documentation that indicated a copy of the consent forms were offered to the client.
Client #3 was admitted on March 15, 2023 and was active at the time of inspection. There were release of information forms to a treatment provider, funding source, urinalysis laboratory, mental health provider, emergency contact, and transportation service that were signed and dated by the client on March 15, 2023; however, there was no documentation that indicated a copy of the consent forms were offered to the client.
Client #4 was admitted on February 20, 2023 and was discharged on March 12, 2023. There were release of information forms to a urinalysis laboratory, transportation service, emergency contact, funding source, a person and pharmacy that were signed and dated by the client on February 20, 2023; however, there was no documentation that indicated a copy of the consent forms were offered to the client.
Client #6 was admitted on April 27, 2023 and was discharged on August 17, 2023. There were release of information forms to a person and emergency contact that were signed and dated by the client on April 27, 2023; however, there was no documentation that indicated a copy of the consent forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent will be in writing and include, but not be limited to indicating that the client either received a copy of the consent or did not want a copy of the consent.
Staff will be reminded in annual Confidentiality Trainings that it should be indicated on the consent form whether or not the participant wanted a copy of the consent form.
Program Director and the QI Specialist will conduct regular health record reviews to ensure staff are adhering to this requirement.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on review of the facility ' s unusual incident reports, the facility failed to notify the Department within 3 business days of a physical or sexual assault by staff or a client.
On May 3, 2023, July 5, 2023, and August 14, 2023, there were reports of a physical assault by staff or client, and the facility had 3 business days to report the incident to the Department. None of the incidents were reported to the Department at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director will ensure that all unusual incidents are reported to the Department within 3 business days. Any physical or sexual assault is an unusual incident and will be reported to the Department within 3 business days.
The Unusual Incident Reporting Licensing Alert dated 12/24/2018 was reviewed with all staff during the monthly staff meeting on 11/15/2023. The expectation is that this will be followed going forward.
QI Specialist will follow up with program to ensure that unusual incidents are reports to DDAP within 3 business days.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on review of the facility ' s unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire or ambulance personnel.
On March 23, 2023, March 28, 2023, August 15, 2023, and September 1, 2023, police, fire or ambulance were called to the facility, and the facility had 3 business days to report the incident to the Department. None of the incidents were reported to the Department at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director will ensure that all unusual incidents are reported to the Department within 3 business days. Presence of police, fire, or ambulance is an unusual incident and will be reported to the Department within 3 business days. The Unusual Incident Reporting Licensing Alert dated 12/24/2018 was reviewed with all staff during the monthly staff meeting on 11/15/2023. The expectation is that this will be followed going forward.
QI Specialist will follow up with program to ensure that unusual incidents are reported to DDAP within 3 business days.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for having the name of the person, agency or organization included on consent to release information forms were submitted and approved by the Department for the October 9, 2020, November 10, 2021, and November 17, 2022 annual licensing inspections. Not having the name of the person, agency or organization included on consent to release information forms was again found to be a deficiency in the October 19, 2023 licensing inspection.
This is a repeat citation from the November 17, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure compliance with this plan of correction (POC) Citation # A0404 the following actions will occur. Effective 11/17/23, the Regional Director started to review POC compliance with the Program Director during their regularly bi-weekly scheduled supervisions. This will continue to occur every other Tuesday at 1:00pm. Effective 1/11/24 the Quality Improvement Specialist will review the POC and participant records to ensure overall POC compliance is being adhered to. This will continue to occur at the facility on the second Thursday of each month. The required quality improvement changes to the POC have been reviewed, completed, and implemented to ensure the regulatory sustainability of the program. |