INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 22 and 23, 2009 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 November 25, 2009.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of ten personnel files, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training.
Findings:
During the annual licensure review visit on October 22 & 23, 2009, ten personnel records were reviewed. Two of ten personnel files did not contain documentation of required HIV/AIDS 6 hour training. Record #6 showed that a counselor hired on 9/18/08, had not received the training within the first year of employment. Additionally, there was no documentation in Record #5 showing that a counselor hired on 3/31/08 had received the required training within the first year of employment.
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Plan of Correction
Part-time counselor (#6)that was out of compliance with the 6 hours of HIV/AIDS training is scheduled to take it on 1/31/10. The second staff person (#5)is a supervisor who completed the HIV/AIDS training on 5/8/97. |
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 the review of two records of discharged residents, the facility failed to document follow up contact in accordance with their policies and procedures.
Findings:
During the Annual Licensure visit on 10/22 & 23, 2009 six resident records were reviewed. Of the six, two were of discharged residents and were required to have a follow up contact within 30 days according to facility policy. Resident record #5 showed a discharge date of 6/26/09 and did not contain documentation of a follow up contact which was due by 7/26/09. Resident record #6 showed a discharge date of 6/24/09 and had no documentation of a follow up which was due by 7/24/09.
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Plan of Correction
Both participants were discharged to another Horizon House service. According to Chapter 709, subchapter D (709.44, b4) followups are not required unless the participant was referred to an outside resource. Our policy and procedure #1342 section 5 titled "Substance Abuse Care and Follow-up" also states that "Aftercare Plans (and follow-up) are not required when participants are referred within Horizon House Drug and Alcohol Outpatient Services." Within Horizon House, follow-up is done by the service that is accepting the participant, in order to maintain the continuity of care. |