INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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
The project failed to document an annual written individual training plan for each employee that was appropriate to that employee's skill level and with input from both the employee and the supervisor in three of four personnel records reviewed.
Employee #2 was hired on December 4, 2018 and was still employed at the time of the inspection. A training plan was documented in the employee's record for the 2020 training year; however, there was no documentation that the plan was developed with input from both the employee and the supervisor.
Employee #3 was hired on September 14, 2020 and was still employed at the time of the inspection. A training plan was documented in the employee's record for the 2020 training year; however, there was no documentation that the plan was developed with input from both the employee and the supervisor.
Employee #4 was hired on August 19, 2019 and was still employed at the time of the inspection. A training plan was documented in the employee's record for the 2020 training year; however, there was no documentation that the plan was developed with input from both the employee and the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 & #3 have updated and signed their individual training plans. Employee #4 is out on leave and her plan will be signed if and when she returns. Individual training plans for new staff will be developed and signed in the first week of orientation. It will be added to the Orientation Checklist. Program Director will review all orientation checklists for new staff within a month of hire. Any discrepancies will be immediately addressed. All staff will review, update, and sign their individual training plans with their supervisor in December of each year. Completed and signed individual training plans will be submitted to program admin by December 31 each year. Any missing plans will be reported to the Program Director for immediate completion.
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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
The project failed to ensure that each staff person 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 in one of six personnel records reviewed.
Employee #5 was hired as a direct care professional on March 5, 2018 and was due to have the communicable disease trainings no later than March 5, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #6 was hired as a direct care professional on May 29, 2018 and was due to have the communicable disease trainings no later than May 29, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #5 & #6 will complete their trainings by November 15, 2020. Program admin will track all trainings. Completed and signed individual training plans and certificates will be submitted to program admin by December 31 each year. The tracker will be submitted to the Program Director for review on a quarterly basis and any outstanding trainings will be addressed in supervision with the staff.
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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
The project failed to ensure that the project director completed at least 12 clock hours of annual training for the facility's January 2019 through December 2019 training year.
Employee #1 was hired on October 1, 2020 and was still employed at the time of the inspection. There were only eight training hours documented in the personnel record for the 2019 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive admin will manage the individualize training plan and certificates of training for the project director. The executive admin will submit the completed training plan by December 31 of each year to the QI Director for the previous and upcoming calendar year. On a quarterly basis, the executive admin will submit any training certificates obtained that quarter to the QI Director. QI Director will notify the Compliance Officer of any unaccounted for trainings.
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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
The project failed to include the name of the person, agency, or organization to whom disclosure would be made to on an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #2 was admitted on September 17, 2020 and was still active at the time of the inspection. A release of information form, signed and dated by the client on September 17, 2020, did not document the name of the person, agency or organization 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
The incomplete release of information form was removed from Client #2s chart. The staff who incorrectly completed the release of information is no longer employed at Horizon House. Staff were reminded in their staff meeting on 10/21/2020 of correct release completion. Any release filed in the health record will first be reviewed by the Records Clerk. Any incomplete releases will be brought to the attention of the supervisor or program director who will immediately address it with staff. Repeated offenses will result in staff training on proper release completion.
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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
The project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in five of seven client records reviewed.
Client #1 was admitted on July 9, 2020 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on July 9, 2020 that allowed for the release of admission forms, PCPC forms and ASAM forms, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #2 was admitted on September 17, 2020 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on September 17, 2020 that allowed for the release of admission forms, PCPC forms and ASAM forms, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on January 16, 2020 and was discharged on February 24, 2020. A release of information form to a government agency was signed and dated by the client on January 16, 2020 that allowed for the release of assessments and medications, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a funding source was signed and dated by the client on January 16, 2020 that allowed for the release of treatment plans, psychiatric summary, medication records and assessments.
Client #5 was admitted on March 6, 2020 and was discharged on June 26, 2020. A release of information form to a funding source was signed and dated by the client on March 6, 2020 that allowed for the release of treatment plans, psychiatric summary and medication records, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on March 8, 2020 and was discharged on October 1, 2020. A release of information form to a funding source was signed and dated by the client on March 8, 2020 that allowed for the release of admission forms, PCPC forms and ASAM forms, all of which exceeds 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
The program has been using the release provided by BHSI but will stop using BHSI release and only use the Horizon House release which doesn't allow for information to be shared outside of what is permitted by 4 Pa code 255.5. Staff were re-educated in their staff meeting on 10/21/2020 of correct release completion. The Director or designee will review 100% of BHSI releases to ensure only permissible information is being released.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The project failed to include a dated signature of the client on an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #5 was admitted on March 6, 2020 and was discharged on June 26, 2020. A release of information form for a funding source was dated on March 6, 2020; however, the consent form was not signed and dated by the client. Additionally, urinalysis screenings were conducted by a laboratory on May 14, 2020, May 21, 2020 and June 18, 2020. The release of information form for the urinalysis laboratory was dated on March 6, 2020; however, the consent form was not signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The releases for Client #5 were removed from the chart. Staff were reminded in their staff meeting on 10/21/2020 of correct release completion. Any release filed in the health record will first be reviewed by the Records Clerk. Any releases with missing signatures will be brought to the attention of the supervisor or program director who will immediately address it with staff. Repeated offenses will result in staff training on proper release completion. Program Director or designee will review 20% of charts per month for proper completion of releases of information. Any discrepancies identified will be addressed in supervision.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services in seven of seven client records reviewed.
Client #1 was admitted on July 9, 2020 and was still active at the time of inspection. The comprehensive treatment plan was developed on August 7, 2020; however, the treatment plan did not document the type and frequency of treatment and rehabilitation services the client was to receive.
Client #2 was admitted on September 17, 2020 and was still active at the time of inspection. The comprehensive treatment plan was developed on September 18, 2020; however, the treatment plan did not document the type and frequency of treatment and rehabilitation services the client was to receive.
Client #3 was admitted on March 23, 2020 and was still active at the time of inspection. The comprehensive treatment plan was developed on April 2, 2020; however, the treatment plan did not document the type and frequency of treatment and rehabilitation services the client was to receive.
Client #4 was admitted on January 16, 2020 and was discharged on February 24, 2020. The comprehensive treatment plan was developed on January 21, 2020; however, the treatment plan did not document the type and frequency of treatment and rehabilitation services the client was to receive.
Client #5 was admitted on March 6, 2020 and was discharged on June 26, 2020. The comprehensive treatment plan was developed on March 3, 2020; however, the treatment plan did not document the type and frequency of treatment and rehabilitation services the client was to receive.
Client #6 was admitted on March 23, 2020 and was discharged on July 23, 2020. The comprehensive treatment plan was developed on April 24, 2020; however, the treatment plan did not document the type and frequency of treatment and rehabilitation services the client was to receive.
Client #7 was admitted on March 8, 2020 and was discharged on October 1, 2020. The comprehensive treatment plan was developed on April 10, 2020; however, the treatment plan did not document the type and frequency of treatment and rehabilitation services the client was to receive.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program staff were retrained in the last staff meeting on 10/21/2020 to include the type and frequency of treatment and rehabilitation services on the treatment plan. Any treatment plan filed in the health record will first be reviewed by the Records Clerk. Any treatment plan that is missing the type and frequency of treatment and rehabilitation services will be brought to the attention of the supervisor or program director who will immediately address it with staff. Repeated offenses will result in staff training on proper treatment plan completion. Program Director or designee will review 20% of charts per month for the inclusion of type and frequency of treatment and rehabilitation services. Any discrepancies identified will be addressed in supervision.
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