INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9-10, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Foundation Medical Services, LLC 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 July 7, 2009.
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Plan of Correction
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709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on the review of the Board of Director's by laws and conversations with the facility director, the facility failed to document that the duties of the governing body included selecting a project director as the person officially responsible to the governing body.
Finding:
The corporation by laws were reviewed on June 9, 2009. Conversations with the facility director occurred on June 9 and 10, 2009. There was no documentation provided that showed the duties of the governing body included selecting a project director as the person officially responsible to the governing body.
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Plan of Correction
The CEO will address and obtain a Board vote at the next regularly scheduled meeting in August 2009.
The measureable outcome: The bylaws will be edited to include processes for selecting a project director.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility's letters of agreement and an interview with the facility director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage.
The findings include:
The review of the facility's letters of agreement and an interview with the facility director occurred on June 9, 2009. The letter of agreement provided for the Butler Hospital had expired in April of 2008. The letter of agreement provided for the Cranberry Hospital expired in May 2008. There were no current letters of agreement provided for either site.
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Plan of Correction
Program Director will review and update the expired written agreement with Butler Hospital by July 10, 2009.
Measureable outcome: A new agreement will be in place by July 10, 2009.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative materials and conversations with the facility director, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
Finding:
The administrative materials were reviewed on June 9, 2009. Conversations with the facility director occurred on June 9 and 10, 2009. There was no documentation that the project had obtained the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the fiscal year ending June 30, 2008.
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Plan of Correction
The CEO will discuss at the Foundations Board meeting in August where the Partners will select/engage an auditor to begin the audit process.
An audit for the Fiscal year ending December 31, 2009 will be conducted (Foundation Medical Services fiscal year runs Jan. 1 through Dec. 31)and a fiscal audit report will be available for the year 2009 by April 2010.
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