INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 9, 2021 through November 10, 2021 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 the facility-submitted Staffing Requirement Facility Report and personnel files, 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 seven personnel records reviewed.
Employee #7 was hired as a case manager on April 29, 2019. The two trainings were due to be completed no later than April 29, 2021. There was no documentation in the personnel record that both the HIV/AIDS training and the TB/STD training were completed at the time of the inspection.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
During agency orientation, new hires will receive an email link to register for HIV/AIDS and TB/STD trainings. Assigned supervisors will review the orientation checklist with new hires during supervision to ensure that staff are registered and attend necessary trainings. Employee #7 will attend BHTEN HIV/AIDS training at next available: January 12/13, 2022 for 6 hours. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training during the facility's July 1, 2020 through June 30, 2021 training year in one of one applicable personnel record.
Employee #4 was hired as a counselor on October 6, 2016. The personnel record documented 22.5 hours of training for the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Completed trainings will be tracked by program Administrative Assistant or Program Director/designee. Clinical staff members will have completed training hours reviewed quarterly during supervision with the goal of attending 6-7 hours of training per quarter. If staff are not meeting required training hours each quarter the Clinical Supervisor will assist staff in locating and registering for suitable trainings to ensure that at least 25 hours of training occur each year. |
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 October 2020 through October 2021 fire drill logs, the facility failed to identify, on the drill log, the amount of time it took for evacuation during the drill conducted on October 9, 2020.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The House Manager will complete Fire Drill logs monthly for each fire drill. Logs will be double checked for completeness by the acting Director or Program Director. QI will review fire drills for completeness at least quarterly and address any discrepancies with program management. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative documentation, the facility failed to develop, and make available to the public, their annual report for the year 2020.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Horizon House Advancement will make the annual report available each year on the Horizon House website. QI will check for the annual report the quarter after the end of the fiscal year and follow up with Advancement and leadership if needed. |
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 the policy and procedure manual and client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in three of seven client records reviewed.
Per the facility's policy and procedure manual, case consultation notes are to be completed at least every 90 days for clients in treatment for less than a year and annually if in treatment for over a year.
Client #3 was admitted on July 13, 2021 and was still active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client #5 was admitted on August 20, 2020 and was discharged on September 22, 2021. A case consultation note was completed on May 13, 2021 with the next one due no later than August 13, 2021; however, there was no case consultation note documented prior to discharge.
Client #7 was admitted on February 8, 2021 and was discharged on October 15, 2021. A case consultation note was completed on April 29, 2021 with the next one due no later than July 29, 2021; however, there was no case consultation note documented prior to discharge.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A monthly calendar for Case Consultations was created so that participants are reviewed each month on a rotating basis. The Clinical Supervisor will update the calendar monthly. The Clinical Supervisor will ensure that Case Consultations are completed according to the schedule and review any discrepancies with Drug and Alcohol Specialists during supervision. QI will monitor that Case Consultations are done at least every three months in accordance to agency policy during quarterly chart reviews. Client #3 received a case consultation on 11/18/2021. |
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 an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed.
Client #5 was admitted on August 20, 2020 and was discharged on September 22, 2021. There was documentation of disclosures to the funding source on September 16, 2021, September 18, 2021, and September 21, 2021; however, the consent to release information form to the funding source signed by the client on August 20, 2020 expired on August 20, 2021 and a new, updated release form was not signed by the client prior to the disclosures.
Client #6 was admitted on December 29, 2020 and was discharged on September 23, 2021. There was documentation of disclosures to the funding source on September 20, 2021, September 21, 2021, and September 22, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Case Managers will monitor end dates for Releases so that new releases may be obtained prior to disclosures. QI will monitor for current, accurate Releases during quarterly chart reviews and advise program management of any errors. Additional training will be provided to staff when needed if errors are routinely made and will be reviewed in supervision. |
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 a disclosure was to be made to on release of information forms in two of seven client records reviewed.
Client #1 was admitted on April 22, 2021 and was still active at the time of inspection. There was a release of information form, signed and dated by the client on April 22, 2021, that did not document to whom the disclosure would be made to.
Client #3 was admitted on July 13, 2021 and was still active at the time of inspection. There was a release of information form, signed and dated by the client on July 13, 2021, that did not document to whom the disclosure would be made to.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case Managers ensure that the name of the person or agency to whom disclosures are made are on the release. QI will monitor for current, accurate Releases during quarterly chart reviews and advise program management of any errors. Additional training will be provided to staff when needed if errors are routinely made and will be reviewed in supervision. The releases without an identified person to whom the disclosure would be made were removed from charts for clients #1 and #3.
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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 project failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) in six of seven client records reviewed.
Client #1 was admitted on April 22, 2021 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on April 22, 2021, that allowed for the release of assessments and demographic information, which exceeded the limits established by 4 Pa. Code 255.5.
Client #2 was admitted on February 22, 2021 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on February 22, 2021, that allowed for the release of assessments and demographic information, which exceeded the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on July 13, 2021 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on July 13, 2021, that allowed for the release of assessments and demographic information, which exceeded the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on December 8, 2020 and was discharged on April 16, 2021. A release of information form to a government agency was signed and dated by the client on December 8, 2020, that allowed for the release of assessments and demographic information, which exceeded the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on August 20, 2020 and was discharged on September 22, 2021. A release of information form to a government agency was signed and dated by the client on August 20, 2020, that allowed for the release of assessments, which exceeded the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on February 8, 2021 and was discharged on October 15, 2021. A release of information form to a government agency was signed and dated by the client on February 8, 2021, that allowed for the release of assessments, which exceeded the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Susquehanna Park Releases will be revised to ensure that only allowable disclosures are made dependent on the outside party to whom the information is being released. Releases will be reviewed during quarterly chart reviews and errors in disclosures will be addressed during supervision. The releases allowing for the release of assessments and demographic information were removed from charts #1, #2, #3 and new releases with the correct, limited amount of information to be shared were created for all three charts. |
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 a review of the facility's unusual incident report logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident involving physical or sexual assault by staff or client.
An incident involving the physical assault by staff or client occurred on October 4, 2021; however, there was no documentation that the incident was reported to the Department.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Incidents reports will be submitted to QI within 24 hours. QI will review incidents for those that must be submitted to DDAP and will enter the event in the system. The date submitted to DDAP will be captured by the internal incident monitoring tracking. QI will submit a monthly report of events in the DDAP system to Susquehanna Park staff to verify all need events were submitted and approved. |
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 a review of the facility's unusual incident report logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident involving the on-site presence of fire, police or ambulance personnel.
There were two incidents involving the presence of police personnel that occurred on May 25, 2021; however, there was no documentation that either of the incidents were reported to the Department.
There was an incident involving the presence of ambulance personnel that occurred on May 4, 2021; however, the incident was not reported to the Department until May 11, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Incidents reports will be submitted to QI within 24 hours. QI will review incidents for those that must be submitted to DDAP and will enter the event in the system. The date submitted to DDAP will be captured by the internal incident monitoring tracking. QI will submit a monthly report of events in the DDAP system to Susquehanna Park staff to verify all need events were submitted and approved. |