INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2022 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(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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that there were written individual training plans, developed with input from the employee and the supervisor, for each employee in two of six personnel records reviewed.
Employee#1 was hired as the project director on October 1, 2000. There was no individual training plan for the current training year documented in the personnel record at the time of the inspection.
Employee#2 was hired as the facility director on February 14, 2022. There was no individual training plan for the current training year documented in the personnel record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 - individual training plan will be completed by 12/13/2022.
The executive director will be responsible for the completion of the training plan for employee #1. Moving forward Human Resource will oversee the completion of the individual training plan.
Employee #2 - individual training plan will be completed by 12/13/2022.
Employee #2 supervisor, Division Director will participate in the completion of the individual training plan for this employee.
Moving forward Human Resources will oversee the completion of the individual training plan. |
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 the Staffing Requirements Facility Summary Report and personnel training records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training for the facility ' s 2021 training year reviewed.
Employee # 4 was hired as a counselor on October 6, 2016. The personnel training record documented 22.5 hours of annual training for the reviewed training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 - this counselor will be responsible for completing the required annual 25 clock hours. The compliance of this POC will be monitored by the Clinical Supervisor. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The bathroom, located on the second floor, had cracked and missing tiles in the floor of the shower stalls, as well as on the outside of the shower stalls below the shower door.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance has been altered to the repairs on the bathroom -
The repairs were completed completed on 12/12/2022.
Moving forward the house manager and the program director will conduct weekly walk throughs to assure that all bathrooms are functional, clean and sanitary.
Any repairs needed maintenance will be contacted immediately.
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705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection, the facility failed to limit smoking to the designated smoking areas.
At the time of the inspection, there was cigarette smoke in the second-floor bathroom, which is not a designated smoking area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The non smoking policy will be revisited with all residents and staff to assure compliance with Horizon House non smoking policy.
The medical department will continue to education residents on the dangers of smoking as well as offering nicotine replacement for any resident that requests assistance. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made on informed and voluntary consent to release information forms in two of seven client records reviewed.
Client #5 was admitted on November 8, 2021 and was discharged September 1, 2022. A release of information form was signed and dated by the client on November 8, 2021; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
Client #7 was admitted on June 13, 2022 and was discharged on October 27, 2022. A release of information form was signed and dated by the client on June 13, 2022; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
This is a repeat citation from the October 9, 2020 and the November 10, 2021 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of November 1, 2022 all consents were revised to include the regulator requirements.
All admissions after November 1, 2022 will have the appropriate consents to meet compliance standards.
The clinical supervisor is the responsible person to assure that all consents are current and within compliance standards. |
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 client records, the facility failed to document a complete client record, which is to include follow-up information, in two of two applicable client records reviewed.
Client # 4 was admitted November 11, 2021 and was discharged June 16, 2022. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 6 was admitted December 21, 2021 and was discharged August 18, 2022. There was no documentation of follow-up information in the record at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will be responsible for assuring that the case managers implement and complete follow-up information on all discharges from Susquehanna Park.
The clinical supervisor will conduct bi-weekly and monthly chart audits on all active and discharge clinical files to assure that the follow-up procedures are being completed. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for having the name of the person, agency or organization included on consent to release information forms were submitted and approved by the Department for the October 9, 2020 and November 10, 2021 annual licensing inspections. Not having the name of the person, agency or organization included on consent to release information forms was again found to be a deficiency in the November 17, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is responsible for assuring that all consents are in compliance.
All consents were updated by the Quality Improvement Department and have been entered into all clinical files as of 11/1/2022. Moving forward all consents will be in compliance with licensing regulations.
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