INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27 and 28, 2007 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 January 2, 2008.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of employee records, the facility failed to document feedback forms in two of two records, #2 and 3.
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Plan of Correction
Effective 12/31/07, the Training Dept staff will make an announcement at the beginning of each training for staff to complete the evaluations and for D&A staff to include their names. The training attendance list will also have asterisks next to the names of D&A staff, so their evaluation completion can be verified before they leave the training. The completed D&A staff training evaluations will be kept in a separate binder in the Training Dept by the Training Dept Administrative Assistant. The Administrative Assistant for the Training Dept will monitor the progress on a quarterly basis. This information will be included in the Divisional Policy and Procedure by 12/31/07. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on the physical plant inspection on November 28, 2007 during renovations, the facility failed to provide mattresses for six of twenty-five beds.
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Plan of Correction
The mattresses were ordered in November 2007, and they arrived in January and are now on the beds. All other mattresses are accounted for (totaling 25) and were placed on the frame the week of 12/17/07. To ensure that this does not recur, the Service Director and the House Manager will monitor the mattress inventory on a semi-annual basis and replace worn or missing mattresses. This will be documented on the Residential Site Checklist form. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection during renovations, the facility failed to provide a wall mirror in each bathroom.
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Plan of Correction
The construction will be completed on 12/31/07, and the mirrors will be installed in each bathroom prior to 12/31/07. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection during renovations, the facility failed to provide privacy for toilets in a bathroom on the third floor.
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Plan of Correction
The construction will be completed on 12/31/07, and the dividers for the toilets will be installed in the third floor bathroom prior to 12/31/07. |
705.7 (b) (1) LICENSURE Food service.
705.7. Food Service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(1) Have a food preparation area with a refrigerator, a sink, a stove, an oven and cabinet space for storage.
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Observations
Based on a physical plant inspection during renovations, the facility failed to have kitchen appliances in place.
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Plan of Correction
The construction will be completed on 12/31/07, and the kitchen appliances will be installed prior to 12/31/07. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection on November 27, 2007, the facility failed to secure a handrail for the steps outside the rear basement outside exit.
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Plan of Correction
The construction will be completed on 12/31/07, and the handrails for the steps outside the rear basement will be installed prior to 12/31/07. |
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 client records on November 28, 2007, the facility failed to obtain an informed and voluntary consent from the client in four of four client records reviewed, #1, 2, 3 and 4. The consent to release information to the funding source, Community Behavioral Health (CBH), indicated that a discharge summary was released which exceeded that allowed under 4 Pa. Code 255.5 in client record #1. The consent to release information to the funding source, Community Behavioral Health (CBH), indicated that client medication was released which exceeded that allowed under 4 Pa. Code 255.5 in client record #2. Information released to the Single County Authority, CODAAP, exceeded that allowed under 4 Pa. Code 255.5 in three of three client records reviewed, #2, 3 and 4. The specific information to be disclosed was identified as the "continuing care plan" which was the aftercare plan.
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Plan of Correction
4Pa. Code 255.5
In the January 08 clinical meeting, the program director will train the staff on obtaining informed and voluntary consent forms for each participant.
In the January 2008 staff meeting, the program director will also review with the clinical staff information that may be provided to meet the 4Pa. Code 255.5 standard. The Consent to Release Information form (to funding source) was updated to reflect only the items that can be released according to 4. PA. Code 255.5. The Program Director will monitor progress through monthly record audits. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on November 28, 2007, the facility failed to document a complete drug and alcohol history in four of four client records reviewed, #1, 2, 3 and 4. Length and patterns of use were missing in #1, 2, 3 and 4. Complete histories of substances abused were missing in two of four client records reviewed, #1 and 2.
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Plan of Correction
The Biopsychosocial will be revised by 2/1/08 to reflect the complete drug and alcohol histories of participants, including the length and patterns of use. The staff will be trained in the February 2008 staff meeting by the program director on including the complete history of substances abused, and to include the participant's perception of use on the Biopsych. The Program Director will monitor compliance via monthly record audits. |
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 client records on November 28, 2007, the facility failed to document a complete psychosocial evaluation in four of four client records reviewed, #1, 2, 3 and 4. Psychosocial evaluations focused on identifying goals for the client and contained a limited clinical assessment of the client's assets/strengths, support systems, coping mechanism, negative factors which might inhibit treatment and the client's attitude toward treatment.
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Plan of Correction
The Biopsychosocial evaluation will be revised by 2/1/08 to include a clinical assessment of the participant's assets/strengths, support systems, coping mechanism, negative factors that may impede recovery, and the participant's attitude toward treatment. The Clinicians will be trained on the revised form in the February 2008 staff meeting. Staff will also be trained to document complete Biopsychosocial evaluations. The Program Director will monitor progress through monthly record audits. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a physical plant inspection on November 27,2007, the facility had 26 beds that exceeded the authorized maximum capacity of 25 beds by one. The additional bed was a portable bed which was stored in a third floor closet. Based on an interview, this portable bed was placed in the community room and used whenever there was an inebriated client who needed one on one supervision. This practice also exceeds the treatment for which the facility is licensed as the facility does not have a license for detoxification.
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Plan of Correction
The portable bed has been donated to a non-profit organization and will be delivered by 12/31/07. The Program Director will monitor the physical site on a semi-annual basis to ensure that there are no disposable beds on site. |