INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 22, 2024 through October 23, 2024 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an administrative review, the facility failed to present, to the Department licensing representatives, the completed plan documenting the qualifications and training of the project's staff at the time of the project's site visit.
At the time of the inspection, the facility had been unable to provide a completed and accurate Staffing Requirements Facility Summary Report, which documents staff qualifications and trainings, after multiple requests and attempts by the Department licensing representative at providing technical assistance.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, the Program Director (Facility Director) and Program Admin will use the Staffing Requirements Facility Summary Report as a mechanism for tracking the program required trainings. This will be reviewed and updated at least monthly by the Program Director and Program Admin to ensure that all staff are in compliance with training requirements and credential renewals. The Regional Director and Program Director will ensure that the Staffing Requirements Facility Summary Report is fully completed at least 4 weeks prior to the licensing inspection. QI will ensure that this report is current and ready for DDAP submission at least 2 weeks prior to the licensing visit, and that the Cover Sheet is signed and dated by the Program Director. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel files, the facility failed to ensure each counselor met the educational qualifications of the position in one of three applicable personnel records reviewed.
Employee #7 was hired as a counselor on August 5, 2024. The employee has a bachelor's degree; however, there was no documentation, in the personnel record or on the degree itself, indicating what the degree's major was. Therefore, the Department licensing representative was unable to verify if the major was qualifying at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
HR and the Program Director will review all applicants for positions at the program before they are hired, including temp staff. The credentials of the applicant will be compared with the regulatory requirements, and if the applicant does not meet the requirements, they will be declined. A list of the staff qualification requirements is now posted in the Program Director's office as an easy access for reference. The temp staff (employee #7) was terminated effective 11/26/24. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on an administrative review, the facility failed to complete and document an assessment of staff training needs, which is a policy and procedure within the comprehensive staff development program for agency personnel.
Per the staff development program procedure, there was no assessment of staff training needs completed and documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, the Program Director (Facility Director) will ensure that 30-60 days before the end of the calendar training year, each staff member will complete the Training Needs Assessment. Once completed, this will be reviewed by the Program Director to determine the training needs for staff. The information gathered from all the Training Needs Assessment will be used to develop the Overall Staff Training Needs Plan that will shape the Individual Training Plan for staff going into the new training year. The Regional Director will include this as an agenda item in their Supervision to ensure that this is completed. The Program Director will also include a calendar reminder to ensure that this is initiated 30-60 days before the end of the training year. The Regional Director and QI will send reminders during November and December to ensure that this is being done. These will be submitted to QI by the 5th of the first month of the new training year. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on an administrative review, the facility failed to complete and document an overall plan for addressing the staff training needs, which is a policy and procedure within the comprehensive staff development program for agency personnel.
Per the staff development program procedure, there was no overall staff training needs plan completed and documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, the Overall Staff Training Needs Plan Assessment of staff training needs will be completed in December each year, once the Training Needs Assessment are completed by staff. The Overall Staff Training Needs Plan Assessment will be used to complete the Individual Training Plan for staff in December each year. The Regional Director and QI will send reminders during November and December to ensure that this is being done. This will be reviewed and approved by the Regional Director in December and will be submitted to the QI Dept by the 5th of the first month in the new calendar year. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on an administrative review, the facility failed to complete and document an annual evaluation of the overall training plan, which is a policy and procedure within the comprehensive staff development program for agency personnel.
Per the staff development program procedure, there was no annual overall training plan evaluation completed and documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director shall review annually if the training needs identified on the Individual Training Plan were met and reevaluate if the needs are changing for the upcoming year. This will also be documented on the designated section of Individual Training Plan at the end of the training year. The Program Admin will review all completed Individual Training Plans to ensure that they were fully completed and that they include the evaluation of staff training needs from the training year that just ended. The completed Individual Training Plans with the evaluation section completed will be submitted to the QI Dept by the 5th of the first month in the new calendar year. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan was developed annually, with input from both the employee and the supervisor, in three of six applicable personnel records reviewed.
Employee #2 was hired as the facility director on October 7, 2023. There was no documentation of an individual training plan for the current training year in the personnel record as of the date of the inspection.
Employee #5 was hired as a counselor on August 12, 2024. There was no documentation of an individual training plan for the current training year in the personnel record as of the date of the inspection.
Employee #6 was hired as a counselor on February 27, 2023. There was no documentation of an individual training plan for the current training year in the personnel record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regional Director, Program Director & Clinical Supervisor will ensure that appropriate Annual Individual Training Plans with input from both Employee & Supervisor are completed by December each year and reviewed monthly during Supervision and training schedules. The current Individual Training Plan will be included as part of the Staff Quantitative Report that will be developed to capture all regulatory requirements. The Program Director and Program Admin will be responsible for completing this Staff Quantitative Report, and QI will review during monthly site visits and the Regional Director will review at least quarterly. Any discrepancy observed by both QI or the Regional Director will be immediately addressed by the Regional Director. |
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 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 training within the regulatory timeframes in nine of eleven applicable personnel records reviewed.
Employee #6 was hired as a counselor on February 27, 2023 and was due to receive the HIV/AIDS training and the TB/STD training no later than February 27, 2024; however, there was no documentation provided indicating the HIV/AIDS training and the TB/STD training was completed as of the date of the inspection.
Employee #8 was hired as a residential coordinator on April 25, 2022 and was due to receive the HIV/AIDS training and the TB/STD training no later than April 25, 2024; however, there was no documentation provided indicating the HIV/AIDS training and the TB/STD training was completed as of the date of the inspection.
Employee #10 was hired as a rehabilitation counselor on July 2, 2012 and was due to receive the HIV/AIDS training and the TB/STD training no later than April 25, 2014; however, there was no documentation provided indicating the HIV/AIDS training was completed as of the date of the inspection.
Employee #11 was hired as a rehabilitation counselor on March 28, 2022 and was due to receive the HIV/AIDS training and the TB/STD training no later than March 28, 2024; however, there was no documentation provided indicating the HIV/AIDS training and the TB/STD training was completed as of the date of the inspection.
Employee #12 was hired as a rehabilitation counselor on June 19, 2019 and was due to receive the HIV/AIDS training and the TB/STD training no later than June 19, 2021; however, however, there was no documentation provided indicating the HIV/AIDS training was completed as of the date of the inspection.
Employee #13 was hired as a rehabilitation counselor on May 9, 2022 and was due to receive the HIV/AIDS training and the TB/STD training no later than May 9, 2024; however, there was no documentation provided indicating the HIV/AIDS training and the TB/STD training was completed as of the date of the inspection.
Employee #14 was hired as a rehabilitation counselor on August 4, 2008 and was due to receive the HIV/AIDS training and the TB/STD training no later than August 4, 2010; however, there was no documentation provided indicating the HIV/AIDS training was completed as of the date of the inspection.
Employee #15 was hired as a rehabilitation counselor on April 25, 2022 and was due to receive the HIV/AIDS training and the TB/STD training no later than April 25, 2024; however, there was no documentation provided indicating the HIV/AIDS training and the TB/STD training was completed as of the date of the inspection.
Employee #16 was hired as a rehabilitation counselor on December 13, 2004 and was due to receive the HIV/AIDS training and the TB/STD training no later than December 13, 2006; however, there was no documentation provided indicating the HIV/AIDS training was completed as of the date of the inspection.
This is a repeat citation from the October 19, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director & Clinical Supervisor will ensure that all clinical staff including rehabilitation counselors will take this training by December 16, 2024 and be reflected in their training record. The Program Director will track the training completion on the Staffing Requirements Facility Summary Report, and will review it at least monthly to ensure that it is updated and that staff are in compliance with all required trainings. The Regional Director will review the Staffing Requirements Facility Summary Report at least quarterly to ensure that it is being completed with staff training. The Program Admin will track the trainings for all staff on the Staffing Requirements Facility Summary Report. QI will review the report during monthly site visits, and any discrepancy will immediately be brought to the attention of the Regional Director who will address it. |
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 and staff schedules, the facility failed to ensure there was a sufficient number of staff persons certified in CPR and trained in first aid, so that at least one person trained is onsite during the project's hours of operation.
The facility provides inpatient rehabilitation services, and the project's hours of operation are 24 hours per day and 7 days per week. The staff schedules for the time period of August 1, 2024 through October 22, 2024 were reviewed.
There was no CPR certified and first aid trained staff person onsite during the night hour of 10:00 PM to 11:00PM on the following August 2024 through October 2024 dates: August 7, 9, 14, 16, 21, 23, 30; September 4, 5, 11, 13, 18, 20, 25, 27; and October 1 2, 3, 4, 7, 8, 9, 10, 11, 14, 15, 16, 17, 18, 21, 22.
This is a repeat citation from the October 19, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor will ensure there is a sufficient number of staff persons certified to ensure there is at least one certified CPR and First Aid staff on all shifts. The Program Director and Program Admin will track the training completion on the Staffing Requirements Facility Summary Report, and will review it at least monthly to ensure that it is updated and that staff are in compliance with all required trainings. The Regional Director will review the Staffing Requirements Facility Summary Report at least quarterly to ensure that the CPR and First Aid trainings are being completed in sufficient numbers to ensure shift coverage. QI will review the Staffing Requirements Facility Summary Report during monthly visits to also ensure that the CPR and First Aid trainings are being completed in sufficient numbers to ensure shift coverage. Any discrepancies will immediately be brought to the attention of program management with follow up to ensure that it is promptly addressed. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and the facility director completed at least 12 clock hours of annual training in one of two applicable personnel records reviewed.
Employee #1 was hired as the project director on October 1, 2000. There were 0 hours of training documented during the facility's July 1, 2023 through June 30, 2024 training year reviewed.
This finding was reviewed with facility staff during the inspection process.
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Plan of Correction
The Program Director and Clinical Supervisor will ensure training certificates are kept in a binder to ensure training hours are documented. The Program Director and Program Admin will track the training completion on the Staffing Requirements Facility Summary Report and keep certificates. It will be reviewed at least monthly to ensure that it is updated and that staff are in compliance with all required trainings. The Regional Director will review the Staffing Requirements Facility Summary Report at least quarterly. QI will review the Staffing Requirements Facility Summary Report during monthly visits to also ensure trainings and certificates documented. Any discrepancies will immediately be brought to the attention of program management with follow up to ensure that it is promptly addressed.
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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 each counselor completed at least 25 clock hours of annual training in two of two applicable personnel records reviewed.
Employee #3 was hired as a counselor on April 11, 2022. There were 0 hours of training documented during the facility's July 1, 2023 through June 30, 2024 training year reviewed.
Employee #6 was hired as a counselor on February 27, 2023. There were 0 hours of training documented during the facility's July 1, 2023 through June 30, 2024 training year reviewed.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Program Director and Clinical Supervisor will ensure that each counselor complete 25 hours of training during the year, monitored and tracked on the individual training plan.
Program Director and Program Admin will track the training completion and hours for all staff on the Staffing Requirements Facility Summary Report, and will review it at least monthly to ensure that it is updated and that staff are in compliance with all required trainings. The Regional Director will review the Staffing Requirements Facility Summary Report at least quarterly to ensure that it is being completed with staff training and hours. Any discrepancy will immediately be addressed by the Regional Director. QI will review the Staffing Requirements Facility Summary Report during monthly site visits and address any discrepancy identified with program management.
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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.
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Observations
Based on a physical plant inspection conducted on October 23, 2024, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility were unobstructed.
At the time of the inspection, the second-floor emergency exit door was blocked by two large, yellow mop buckets.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director & House Manager will ensure that no exits are blocked. The staff will conduct rounds of the physical site on each shift and check each exit. This will be documented on the Mandatory Rounds Sheet that is kept in a Binder. Staff will ensure that if any issues are identified, that they are immediately addressed. If it's an issue that staff are unable to immediately address, the House Manager and our Real Estate Dept. will be notified so the issue can be addressed. Going forward, the Program Director will review the Rounds Book in each Morning Team Meeting Monday-Friday and address any identified issues. Regional Director will review with Program Director in Supervision to ensure that this is being done. During site visits, QI will check to ensure that the Rounds Sheet is being completed on each shift. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in eight of nine applicable personnel records reviewed.
Employee #5 was hired as a counselor on August 12, 2024. The fire extinguisher training was due upon employment; however, the training was provided to the employee on October 17, 2024.
Employee #6 was hired as a counselor on February 27, 2023. There was no documentation the fire extinguisher training was provided as of the date of the inspection.
Employee #7 was hired as a counselor on August 5, 2024. There was no documentation the fire extinguisher training was provided as of the date of the inspection.
Employee #17 was hired as rehabilitation counselor on March 25, 2024. The fire extinguisher training was due upon employment; however, the training was provided to the employee on October 17, 2024.
Employee #18 was hired as a cook on January 2, 2024. The fire extinguisher training was due upon employment; however, the training was provided to the employee on October 17, 2024.
Employee #19 was hired as a peer support specialist on June 3, 2024. The fire extinguisher training was due upon employment; however, the training was provided to the employee on October 17, 2024.
Employee #20 was hired as a peer support specialist on May 20, 2024. The fire extinguisher training was due upon employment; however, the training was provided to the employee on October 17, 2024.
Employee #21 was hired as a peer support specialist on May 6, 2024. The fire extinguisher training was due upon employment; however, the training was provided to the employee on October 17, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The House Manager and Program Director will ensure that all new staff receive the Fire Extinguisher Training upon employment. This will be added to the Staff Quantitative Report that will be created by QI where the Program Admin can track. Program Director will ensure that there is a calendar tickler that follows the week of New Hire Orientation (biweekly - every other week), to ensure that all new staff receive the Fire Extinguisher training. The Regional Director will provide oversight during Supervisions with the Program Director to ensure that this training is being completed by all new staff in a timely manner. Any discrepancy will be addressed by the Regional Director. QI will review the Staff Quantitative Report during monthly visits and any discrepancy will be immediately addressed with program management. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in eight of nine applicable personnel records reviewed.
Employee #5 was hired as a counselor on August 12, 2024. The emergency preparedness training was not provided to the employee until October 17, 2024.
Employee #6 was hired as a counselor on February 27, 2023. There was no documentation the emergency preparedness training was to the employee as of the date of the inspection.
Employee #7 was hired as a counselor on August 5, 2024. There was no documentation the emergency preparedness training was to the employee as of the date of the inspection.
Employee #17 was hired as rehabilitation counselor on March 25, 2024. The emergency preparedness training was not provided to the employee until October 17, 2024.
Employee #18 was hired as a cook on January 2, 2024. The emergency preparedness training was not provided to the employee until October 17, 2024.
Employee #19 was hired as a peer support specialist on June 3, 2024. The emergency preparedness training was not provided to the employee until October 17, 2024.
Employee #20 was hired as a peer support specialist on May 20, 2024. The emergency preparedness training was not provided to the employee until October 17, 2024.
Employee #21 was hired as a peer support specialist on May 6, 2024. The emergency preparedness training was not provided to the employee until October 17, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The House Manager and Program Director will ensure that all new staff receive Emergency Preparedness and Disaster Training upon employment. This will be added to the Staff Quantitative Report that will be created by QI where the Program Admin can track all the staffing regulatory requirements.
Program Director will ensure that there is a calendar tickler that follows the week of New Hire Orientation (biweekly - every other week), to ensure that all new staff receive the Emergency Preparedness and Disaster Training. The Regional Director will provide oversight during Supervisions with the Program Director to ensure that this training is being completed by all new staff in a timely manner. Any discrepancy will be addressed by the Regional Director. QI will review the Staff Quantitative Report during monthly visits and any discrepancy will be immediately addressed with program management.
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705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the November 2023 through September 2024 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
The facility provides inpatient residential services, and their hours of operation is 24 hours per day and 7 days per week. All of the reviewed fire drills were conducted on Monday through Friday. There were no fire drills conducted on Saturdays or Sundays during the reviewed period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director & House Manager trained all weekend staff to ensure fire drills are completed on every shift on November 20, 2024. Program Director and House Manager will review the timing of the monthly fire drills to ensure that drills are conducted on different days of the week and at difference times of the day and night and on different staffing shifts. Program Admin will review the fire drills to ensure that the program is in compliance with this requirement. During monthly site visits, QI will review the Health and Safety Binder to ensure that drills are being done according to regulatory requirements. Any discrepancy will immediately be addressed with program management to ensure that it is corrected moving forward. |
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 and the facility policy and procedure manual, the facility failed to ensure they were following four of the project's written procedures for the management of treatment/rehabilitation services in six of nine client records reviewed.
First, the facility policy and procedure regarding Health Record Documentation Standards stated that when an incident occurs, the appropriate staff must document the facts of the occurrences in the health record and complete an incident report by the end of the shift.
Client #4 was admitted on August 19, 2024 and was discharged on September 3, 2024. There was documentation of an After Visit Summary from an ER visit on August 22, 2024; however, there was no documentation in the record regarding the specific nature and details of the incident or the need for the ER visit.
Client #6 was admitted on January 19, 2024 and was discharged on May 24, 2024. There was documentation of an After Visit Summary from an ER visit on February 13, 2024; however, there was no documentation in the record regarding the specific nature and details of the incident or the need for the ER visit.
Second, the facility policy and procedure regarding Weapons, Illicit Drugs and Violence stated that "if any staff suspects a participant/visitor of drug use, they must follow the procedures described in the policy." The listed procedures, described in the policy, included "the participant, if appropriate, may be offered the opportunity to discuss the issue with clinical staff and/or Peer support, and also be offered a referral to a drug treatment facility if the program is not equipped to treat the issue."
Client #4 was admitted on August 19, 2024 and was discharged on September 3, 2024. Per documentation in the client record, the client was taken to the ER via 911/ambulance on August 20, 2024, so the client could be "evaluated for a possible overdose." The client then visited the ER on August 22, 2024, for an unknown reason as the reason was not documented in the record. On August 31, 2024, the client was taken to the ER again via 911/ambulance and documentation in the record indicated the visit was due to the client being "clearly under the influence of some unknown substance other than methadone." Upon the client's return from the ER and subsequent discharge, there was no documentation of a referral to another licensed drug treatment facility that was equipped to treat the issue. The client was given a referral to an external organization for homeless people.
Third, the facility policy and procedure stated the client's emergency contact would be notified within 12 hours of a client leaving AWOL or against medical advice.
Client #8 was admitted on June 21, 2024 and left against medical advice on June 28, 2024. There was no documentation in the record that the emergency contact was notified of the client leaving against medical advice as of the date of this inspection.
Finally, the facility policy and procedure regarding Progress Notes stated that progress notes would be written after any significant participant contact.
Client #2 was admitted on April 8, 2024 and was active at the time of the inspection. There was an individual session conducted on May 10, 2024; however, the counselor completed the progress note on June 10, 2024. Additionally, there were individual sessions conducted on May 14, 2024, May 31, 2024, and June 6, 2024; however, the counselor completed the progress notes for all three sessions on June 21, 2024.
Client #3 was admitted on May 29, 204 and was active at the time of the inspection. There were individual sessions conducted on July 25, 2024, August 22, 2024, and August 29, 2024; however, the counselor completed the progress notes for all three sessions on September 19, 2024. Additionally, there was an individual session conducted on June 4, 2024; however, the counselor completed the progress note on July 3, 2024. Also, there was an individual session conducted on July 16, 2024; however, the counselor completed the progress note on August 5, 2024. Finally, there was an individual session conducted on September 19, 2024; however, the counselor completed the progress note on September 27, 2024.
Client #6 was admitted on January 19, 2024 and was discharged May 24, 2024. There was an individual session conducted on February 9, 2024; however, the counselor completed the progress note on February 23, 2024. Additionally, there were individual sessions conducted on May 14, 2024 and May 21, 2024; however, the counselor completed the progress notes for both sessions on May 27, 2024.
Client #7 was admitted on July 18, 2024 and was discharged on October 13, 2024. There was an individual session conducted on July 23, 2024; however, the counselor completed the progress note on August 5, 2024. Additionally, there was an individual session conducted on August 6, 2024; however, the counselor completed the progress note on August 20, 2024. Also, there was an individual session conducted on August 22, 2024; however, the counselor completed the progress note on September 4, 2024. Finally, there was an individual session conducted on August 28, 2024; however, the counselor completed the progress note on September 19, 2024.
This is a repeat citation from the October 19, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The program's Health Record Documentation Standards policy will be reviewed with the nurses 12/4/24 to ensure clarity on the requirement to document ER visits in the health record that include the reason for the visit. Staff will sign off on the Health Record Documentation Standards Policy to confirm their understanding of the procedures.
After the training, QI will conduct monthly audits of the records to ensure that staff are adhering to the requirements. Audit findings will be reviewed with program management staff, and Staff found non-compliant will receive coaching, re-training, or disciplinary action as necessary. The documentation processes for ER visits will be added as a standing agenda item for quarterly staff meetings, and feedback from the nurses on barriers to compliance will be solicited and addressed.
The program's policy on Weapons, Illicit Drugs, and Violence P&P will be reviewed with all staff in the next staff meeting on 12/18/24 to ensure that staff understand the procedures for handling suspected substance use, including: 1) Offering the opportunity for clinical discussions and peer support, 2) Engaging clinical staff or Peer Support staff to offer participants the opportunity to discuss drug use, 3) Referring participants to appropriate drug treatment facilities when the program is not equipped to treat the issue, 4) Identifying and managing suspected substance, 5) Documenting all actions taken in the participant's health record. Staff will sign off on the Weapons, Illicit Drugs, and Violence P&P to acknowledge understanding.
The Health Record Review tool was updated on 11/26/24 to include all required actions (offering clinical discussions, referrals as needed, and documentation) after a suspected or confirmed drug use incident.
Subsequently, both program management and QI will conduct monthly audits of participant health records to ensure compliance with the policy, focusing on incidents involving suspected substance use.
The program's policy on notifying emergency contacts will be reviewed with all staff during the next staff meeting on 12/18/24 to ensure that they understand their responsibility that includes 1) the steps staff must take to notify emergency contacts within 12 hours of a participant leaving AMA or AWOL, 2) the importance of emergency contact notification for participant safety and compliance, and 3) the required documentation in the participant's health record, including the date, time, method of contact, and name of the person notified. Staff will sign off on the Emergency Contact Notification Protocol to acknowledge their understanding of the contents. The Program Director will conduct a record review of all AMA participants to ensure compliance with the Protocol. Results of the reviews will be shared in future staff meetings to identify and address recurring issues.
Counselors responsible for late progress notes have been identified, and the importance of timely documentation will be addressed in their next supervision. The Progress Note P&P will be reviewed in the next staff meeting on 12/18/24 to include 1) The importance of timely and accurate documentation for participant care and compliance, 2) Best practices for efficient and effective note completion, and 3) Consequences of failing to adhere to documentation timelines. Staff will sign off on the Progress Note P&P to demonstrate their understanding.
QI will run a monthly late note report in the EHR to identify staff who continue to write notes late. Staff with repeated documentation delays will be subject to progressive disciplinary action, including re-training, coaching, or disciplinary measures as needed. The timeliness of progress notes will also be a recurring agenda item in the staff meetings.
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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
Based on a review of personnel records, the facility failed to ensure an annual written individual staff performance evaluation were completed, reviewed, and signed by the employee in four of four applicable personnel records reviewed.
Employee #1 was hired as the project director on October 1, 2000. There was no annual written individual staff performance evaluation for the previous year documented in the record as of the date of the inspection.
Employee #2 was hired as the facility director on October 7, 2023. There was no annual written individual staff performance evaluation for the previous year documented in the record as of the date of the inspection.
Employee #3 was hired as a counselor on April 11, 2022. There was no annual written individual staff performance evaluation for the previous year documented in the record as of the date of the inspection.
Employee #6 was hired as a counselor on February 27, 2023. There was no annual written individual staff performance evaluation for the previous year documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Horizon House is in the process of transitioning from paper performance evaluations to electronic, and the electronic systems is undergoing some challenges, which resulted in the performance evaluations not being completed. Horizon House has engaged the electronic system's technical support team to address ongoing issues to ensure the system is fully operational by 3/31/25. Pending the implementation of the electronic system, the Program Director will: 1) Temporarily revert to paper-based performance evaluations to prevent further delays by 12/9/24, 2) Establish a dual process, where paper evaluations are conducted alongside the system rollout until the issues are resolved.
Once the electronic system is implemented, there will be detailed reports and dashboards to allow for easy monitoring of compliance by program management.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to maintain the confidentiality of client identity and records in one of nine client records reviewed.
Client #6 was admitted on January 19, 2024 and was discharged on May 24, 2024. There was a group session progress note, dated July 15, 2024, for another client located in this client's electronic medical record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The incorrectly filed group session progress note was identified and removed from Client #6's EHR record on 11/26/24. The correct placement of the note in the appropriate participant's record has been verified by QI on 11/26/24. In the next staff meeting on 12/18/24, the following will be reviewed by all clinical and administrative staff: 1) The importance of maintaining participant confidentiality and the legal and ethical implications of breaches, 2) Proper procedures for filing and uploading documents into the EMR system, and 3) Steps to verify accurate record placement before finalizing documentation in the EHR system.
Program Director and QI will conduct random reviews of participants' health record in the EHR to ensure all documentation is correctly filed and confidentiality is maintained. Any future misfiled document will be reported to program management who will review with the staff in supervision and if this persist, progressive discipline will ensue.
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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 nine client records reviewed.
Client #5 was admitted on June 10, 2024 and was discharged on September 5, 2024. There was documentation of disclosures to another treatment provider on September 5, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #6 was admitted on January 19, 2024 and was discharged on May 24, 2024. There was documentation of disclosures to another treatment provider on May 24, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This is a repeat citation from the October 19, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical and administrative staff involved in information disclosures will complete mandatory training in the next staff meeting on 12/18/24 focusing on the following, 1) Legal and ethical requirements for obtaining written, informed, and voluntary consent prior to disclosures, 2) Proper completion and filing of consent forms in the participant health record, and 3) Verification procedures to ensure a valid consent form is in place before releasing information. Staff will sign an Attestation indicating their understanding of what was reviewed. This topic will be added to the monthly staff meeting as a reminder to staff to pay attention to information being released.
QI has developed a Disclosure Checklist on 11/26/24 that will be posted in the staff office as a reminder of the procedure before releasing any information externally.
QI and the Program Director will conduct health record reviews in an effort to any areas of noncompliance. Any noncompliance that is identified will be addressed with the staff in supervision, and if it continues, it will result in progressive disciplinary action.
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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 the disclosure on a release of information form in one of nine client records reviewed.
Client #6 was admitted on January 19, 2024 and was discharged on May 24, 2024. A release of information form to another treatment provider was signed and dated by the client on February 27, 2024; however, the purpose of the disclosure was not included on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The importance of documenting the purpose of the disclosure on the release of information form will also be emphasized in the staff meeting on 12/18/24. The following will also be included in the retraining: 1) The required components of a valid release of information form, including the purpose of disclosure, and 2) Proper procedures for verifying that all required fields are completed before obtaining participant signatures.
On the Disclosure Checklist that was completed, it will include staff confirming that all fields were completed, including the purpose of disclosure.
Program management will conduct routine audits of the health record and QI will conduct monthly audits to ensure compliance. Any discrepancy will be addressed with the identified staff during supervision, and if it continues, it will result in progressive disciplinary action.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion in nine of nine client records reviewed.
In every client record reviewed, the client-signed client rights acknowledgement form did not include the notification of this particular regulatory client right.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
QI has updated the Participant's Non-discrimination Statement form. All current participants that did not yet review and sign the form will do so by 12/6/24. This form will also be discussed in the staff meeting on 12/18/24 to emphasize the need to complete it for new admissions. This will also be an ongoing agenda item in the monthly staff meetings to ensure that staff are constantly reminded of its completion.
The form will be added to the Health Record Review tool to ensure that it is completed. QI will conduct monthly audits to ensure that the form is being completed. Any discrepancy will be addressed with the identified staff during supervision, and if it continues, it will result in progressive disciplinary action.
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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 file a written unusual incident report with the Department within 3 business days following an event at the facility that required the presence of police, fire, or ambulance personnel.
There was documentation indicating that police, fire, or ambulance personnel were called to the facility on August 20, 2024, August 31, 2024, and September 4, 2024. However, none of these unusual incidents were reported to the Department at the time of the inspection.
This is a repeat citation from the October 19, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor are responsible for reporting incidents to DDAP within 3 days. A list of unusual incidents that require reporting to DDAP within 3 days was posted in the Program Director and Clinical Supervisor's office on 11/26/24 to ensure that it is readily available for reference. The Program Director will ensure that this is discussed with the Clinical Director in Supervision. The Regional Director will include incident reporting as an ongoing agenda item in Supervisions with the Program Director to ensure that all reportable unusual incidents are being reported within the required timeframe.
QI will conduct random checks of incident reporting to ensure that they are being reported in a timely manner. Any discrepancy will immediately to brought to the attention of the Program Director and Regional Director who will address it.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document the verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan in two of three applicable client records reviewed.
Client #2 was admitted on April 8, 2024 and was active at the time of the inspection. There was a group note, dated October 19, 2024, and titled " Clean the Building, " which gave out work assignments and tasks to the client outside of their living quarters. There was no documentation or verification that the work was an integral part of their treatment plan in the record.
Client #3 was admitted on May 29, 2024 and was active at the time of the inspection. There was a group note, dated October 19, 2024, and titled " Clean the Building, " which gave out work assignments and tasks to the client outside of their living quarters. There was no documentation or verification that the work was an integral part of their treatment plan in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, participants who are assigned work outside of their living quarters will be done only as part of their treatment planning, and their treatment plans will be updated accordingly. The program's Treatment Plan policy regarding participant work as part of treatment will be revised by 12/6/24 to require clear documentation in the participant record verifying: 1) The therapeutic purpose of the work activity, and 2) How the work aligns with the participant's treatment and rehabilitation goals. The revised policy will be discussed in the 12/18/24 staff meeting, and staff will be reminded of 1) The regulatory requirement to verify that participant work is integral to treatment, 2) The process for documenting this connection in the participant health record, and 3) The importance of tailoring work-related tasks to individual treatment plans.
The Program Director will ensure that before signing off on Treatment Plans, she ensures that it reflects the integration of work as needed. The health record review tool was also updated to add this requirement. The Documentation Compliance Training will also be updated to the reflect this requirement. QI will also conduct monthly health record reviews to ensure that documentation reflects the incorporation of work into treatment plans. Findings from the review will be shared with program management, who will discuss the results in monthly staff meetings and follow up with staff accordingly.
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