INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8, 9 and 10, 2008 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 and a plan of correction is due on November 14, 2008.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on an inspection of the facility ' s physical plan on October 9, 2008, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
Findings:
The group rooms have large windows without shades or curtains. Group sessions can be observed from the hallway.
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Plan of Correction
Blinds have been ordered by the facility director as of 10/20/08 for the group rooms. The blinds will be installed in the group room by 1/31/08. The staff will be informed by the facility director in the January 2009 staff meeting that the blinds should be closed when groups are in session in the group room. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on a review of administrative documents and the employee handbook on October 8, 2008, the facility failed to document policy for informing staff of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the personnel record.
Finding: The employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the personnel record was not included in the employee rights section of the policy manual or in the employee handbook.
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Plan of Correction
Horizon House will modify its process of informing staff of the agency process for reviewing and requesting modification of their Personnel Record. The Employee Handbook will be revised to include outlining employee rights and the Agency process. Employees are eligible to inspect the contents in their Personnel Record by making a written request addressed to the Director of Human Resources. At that time, they will be informed of the procedure and conditions governing Personnel Record inspections and be given a copy of the full agency policy. If they feel the Personnel Record contains errors (such as inaccurate or incomplete information) they must make a written request to the Human Resources Director. The Human Resources Director will consider the objections and correct or remove erroneous or improper information. If management decides to retain the disputed information in the file, the employee is entitled to place a rebuttal or memorandum of disagreement in the record identifying specific alleged errors or inaccuracies. In January 2009, each employee will receive a copy of the revised Employee Handbook. Each employee will sign an acknowledgment that they have received it, and new hires thereafter will receive a copy of the revised Employee Handbook during new hire orientation. |
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 facility forms and ten client records on October 8, 9 and 10, 2008, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Findings:
The consent to services form, which included consents to release information on the back side, and all of the consent to release information forms did not allow for verbal revocation of the consent to release information in ten of ten client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 11.
The consent to services form and all of the consent to release information forms in ten of ten client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 11, failed to comply with 42 C.F.R., Subpart C, Subsection 2.32, as they included a statement that "the information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected by this rule".
The consent to services form and all of the consent to release information forms included a reference to Delaware State law regarding the disclosure of information in ten of ten client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 11.
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Plan of Correction
The consents and authorizations will be revised as of 11/15/08 by the QI Dept to allow for verbal revocation of consent to release information. They now have the following statement: "this authorization is subject to revocation at any time." The new forms will be distributed to all counselors by 11/30/08 and discussed in the December staff meeting by the facility director. All staff will be using the revised form by 12/31/08.The consents and authorizations have been revised as of 11/25/08 by the QI Dept to clarify 42 C.F.R., Subpart C, plus meet the Federal regulations 45 C.F.R. 164.508.I understand that my records are protected under the federal regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 that re-disclosure is prohibited, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 C.F.R. Parts 160 and 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. The forms have been revised as of 11/15/08 by the QI Dept to exclude reference to Delaware State law regarding the disclosure of information. The new forms will be distributed to all counselors by 11/30/08 and discussed in the December staff meeting by the facility director. All staff will be using the revised form by 12/31/08. The supervisor, facility director and the QI Specialist will conduct quarterly record reviews to ensure that the correct forms are being used in the records. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of ten client records on October 9 and 10, 2008, the facility failed to obtain an informed and voluntary consent from the client in four of ten client records reviewed.
Findings:
The specific information to be released to the funding source exceeded 255.5 Pa Code in client record #1 and 2. The information to be released to the Coordinating Office for Drug and Alcohol Abuse Programs (CODAAP), included the "continuing care plan".
The specific information to be released exceeded 255.5 Pa Code in client record #6 as information to be released to the funding source included "medications".
The specific information to be released exceeded 255.5 Pa Code in client record #11 as information to be released to probation/parole included "progress notes".
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Plan of Correction
In the January 2009 staff meeting, staff will be trained by the facility director on information to disclose according to Pa Code 255.5. The Team Leader, facility director and the QI Specialist will conduct quarterly record reviews to ensure that the records are in compliance with Pa Code 255.5. |
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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of ten client records on October 9 and 10, 2008, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Findings:
The purpose of disclosure was not identified for consents to release information to HH Employment and the Southeastern Pennsylvania Transportation Authority (SEPTA) and Project Home in client record #3.
The purpose of disclosure was not identified for a consent to release information to a friend in client record #4.
The purpose of disclosure was not identified for consents to release information to HH Employment and the Office of Vocational Rehabilitation (OVR) in client record #9.
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Plan of Correction
In the January 2009 staff meeting, staff will be trained by the facility director on completing the consents in its entirety, and to ensure that the purpose of disclosure is identified on all forms. The Supervisor, facility director and the QI Specialist will conduct quarterly record reviews to ensure that the records are in compliance. |
709.28(c)(6) 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:
(6) Expiration date of the consent.
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Observations
Based on a review of ten client records on October 9 and 10, 2008, the facility failed to obtain an informed and voluntary consent for ten of ten client records reviewed.
Finding:
The Consent to Services form, which included consents to release information to the Forensic Intensive Recovery Program (FIR/IP) case manager, adult parole and probation, funding sources, DeJohn Laboratories, Wheels Transportation, emergency contact and targeted case manager on the back of the form, did not identify an expiration date for the consents to release information in client record #1, 2, 3, 4, 5, 6, 7, 8, 9 and 11.
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Plan of Correction
According to CFR 45: 164.508 (6) (c) (v), A valid authorization must contain at least the following elements: "An expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure. There will be an expiration event for each participant's consent to release information. By indicating "Effective for one year" on the back of the Consent to Service, this is indicating an event. Record reviews will be done quarterly by the QI Specialist, the facility director, and the team leader to ensure compliance. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on a review of ten client records on October 9 and 10, 2008, the facility failed to completely document the administration of medication in five of ten client records.
Fndings:
The facility failed to document the reason for non-administration of prescribed medication on October 1 and 2, 2008 in client record #4.
The facility failed to document the reason for non-administration of prescribed medication on September
3, 5, 10 and 12, 2008 in client record #6.
The facility failed to document the reason for non-administration of prescribed medication on August 5 and 8, 2008 and September 3, 2008 in client record #8.
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Plan of Correction
In the December 2008 staff meeting, staff will be trained by the facility director on documenting the reasons for non-administration of medication on the back of the MOAR. The Supervisor, facility director and the QI Specialist will conduct quarterly record reviews to ensure that the records are in compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of ten client records on October 9 and 10, 2008, the facility failed to document a complete psychosocial evaluation in ten of ten client records where required.
Findings:
The facility did not document psychosocial evaluations to include a clinical assessment of how assets/strengths, support systems and negative factors impact the potential for treatment in client record #1, 2, 3, 4, 5, 6, 7, 8 and 12.
The facility did not document psychosocial evaluations to include coping mechanisms in client record #3, 4, 5, 7 and 12.
The facility did not document a psychosocial evaluation in client record #9.
The psychosocial evaluations were a repeat of historical data in #1, 2, 3, 4, 5, 6, 7, 8 and 12.
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Plan of Correction
The biopsychosocial will be revised by the QI Dept as of 12/15/08 to include coping mechanism. In the January 2009 staff meeting, the facility director will train all counselors on including coping mechanism in the assessment. In addition, counselors will also be trained on documenting psychosocial evaluations to include a clinical assessment of the participants' assets/strengths, supports systems, and negative factors impacting the potential for treatment. The Supervisor, facility director and the QI Manager will conduct quarterly record reviews to ensure that the evaluations are in compliance. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of ten client records on October 8 and 9, 2008, the facility failed to document the treatment plan goals in terms of measurable criteria in five of ten client records where required.
Findings:
The facility failed to document treatment plan goals in terms of measurable criteria in client record #1, 2, 6, 7 and 8.
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Plan of Correction
In the January 2009 staff meeting, staff will be trained by the facility director on documenting treatment plan goals using measurable criteria. The Supervisor, facility director and the QI Specialist will conduct monthly record reviews to ensure that the treatment plans are in compliance. |
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.
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Observations
Based on a review of eleven client records on October 9 and 10, 2008, the facility did not document in the treatment and rehabilitation plan the type and frequency of treatment and rehabilitations services in eleven of eleven client records where required..
Findings:
The facility did not document did not document in the treatment and rehabilitation plan how often individual and/or group sessions were prescribed in client record #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11.
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Plan of Correction
In the January 2009 staff meeting, staff will be trained by the facility director on how to document the frequency of group or individual sessions on the treatment plans. The Supervisor, facility director and the QI Specialist will conduct monthly record reviews to ensure that the records are in compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of eleven client records on October 9 and 10, 2008, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan on the treatment plan update in eight of ten client records where due.
Findings:
The facility did not document complete treatment plan updates in client record #1, 4, 5, 6, 8, 9, 10 and 11.
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Plan of Correction
In the January 2009 staff meeting, staff will be trained by the facility director on documenting an assessment of the participant's progress in relation to the stated goals of the treatment plan update. The Supervisor, facility director and the QI Specialist will conduct quarterly record reviews to ensure that the records are in compliance. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of eleven client records on October 9 and 10, 2008, the facility failed to document a complete aftercare plan in one of one where required.
Finding:
The aftercare plan for #9 did not include goals with time frames or the criteria for re-entry.
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Plan of Correction
In the January 2009 clinical meeting, staff will be trained by the facility director on completing the Aftercare Plan in its entirety, and include the timeframes for the goals. The form will be updated by 12/15/08 by the QI Dept to include the criteria for re-entry, and distributed to staff in the staff meeting. The Supervisor, facility director and the QI Specialist will conduct quarterly record reviews to ensure that the records are in compliance. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of eleven client records and the project's policy and procedure manual on October 9 and 10, 2008, the facility failed to document follow up in four of five client records where due.
Findings:
The facility failed to document any follow-up in client record #9 and 10.
Follow-up was not documented within the required timeframe in client record #11 and 12:
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Follow-up for client record #11 was due on 4/29/08 and documented as completed on 6/20/08.
Follow-up for client record #12 was due on 8/29/08 and documented as completed on 10/10/08.
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Plan of Correction
In the January 2009 staff meeting, the facility director will review the policy and procedure on following up after discharge with counselors. In this meeting, the facility director will train the staff on the proper follow-up procedures based on this policy and procedure. The Supervisor, facility director and the QI Specialist will conduct quarterly record reviews to ensure that the records are in compliance. |