INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7-8, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Foundations 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:
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Plan of Correction
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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 (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Staff #4 was hired as a counselor on August 24, 2020, and was still in the position as of the date of the inspection. The training year that was reviewed was from January 1, 2023, through December 1, 2023. Staff #4's employee record only documented 16.40 hours of annual training for the 2023 year.
This finding was reviewed with facility staff during the licensing inpsection process.
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Plan of Correction
As of January 1, 2024, ED runs report monthly via Relias and distributes to staff to ensure timely completion of training hours. Training hours are discussed monthly during team meetings. ED offers extra opportunities for training hours when they are offered from outside organizations. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as the windows on the door of the group room were uncovered.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 8, 2024, the windows in the group room were covered as soon as it was brought to ED's attention by DDAP surveyor. ED will continue a monthly building walk-through to ensure building meets standards and regulations set forth by DDAP. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of June 23-29, 2024, the patient census was 231. The facility was required to provide at least 23.1 physician hours. There were 14.5 physician hours documented.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the week in question, the physician scheduled was unexpectedly off for medical reasons. This occurred at the end of the week and hours were unable to be made up by other medical providers. ED creates the schedule a month in advance and ensures that hours are being met weekly. This is tracked on a spreadsheet and calendar. ED ensures that there are "buffer" hours embedded into the schedule in case of any issues with providers being unable to cover their assigned hours. Foundations' physician is utilizing telehealth as well, to allow for flexibility to provide hours to clients.
As of June 29, 2024, medical provider hours have been within compliance.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in two out of four applicable records reviewed.
Patient #2 was admitted on October 11, 2022 and was still active at the time of the inspection. In April 2024, the client received 40 minutes of individual psychotherapy and zero group therapy sessions.
Patient #4 was admitted on May 9, 2023, and was still active at the time of the inspection. On July 2024, the patient recieved 30 minutes of individual psychotherapy and 90 minutes of group therapy.
These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
ED runs and reviews a monthly report of service history and shares with clinical staff to ensure hours are being met. Client hours are reviewed weekly during team meetings where plans of action can be discussed.
As of 8/9/2024, ED provided education and training to the clinical team as a reminder to write either a memo or call log that missed appointments (did not show or cancelled by client) are being followed up on and being rescheduled. The administrative assistant was also educated on this to add a memo in if a client reschedules at the front desk.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with one hour per month of therapy during the third and fourth year of treatment in two out of three applicable records.
Patient #1 was admitted on September 8, 2021, and was still active at the time of the inspection. In April 2024 and May 2024 there was no documentation to verify that the patient had received any therapy during these months.
Patient #6 was admitted on June 26, 2024 and was still active at the time of the inspection. In July 2024, the patient received 30 minutes of individual psychotherapy and zero group therapy sessions.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
ED runs and reviews a monthly report of service history and shares with clinical staff to ensure hours are being met. Client hours are reviewed weekly during team meetings where plans of action can be discussed.
As of 8/9/2024, ED provided education and training to the clinical team as a reminder to write either a memo or call log that missed appointments (did not show or cancelled by client) are being followed up on and being rescheduled. The administrative assistant was also educated on this to add a memo in if a client reschedules at the front desk.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in two out of six applicable records reviewed.
Patient #6 was admitted on March 8, 2021and dischrged on May 21, 2024. An annual physical was due on March 8, 2024; however, it was not completed until March 12, 2024.
Patient #8 was admitted on January 24, 2023, and was discharged on June 7, 2024. An annual physical was due on January 24, 2024; however, there was no documentation in the patient 's record of it being completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of March 1, 2024, annual physicals are to be scheduled by nursing to increase compliance. This has shown to improve physicals being scheduled for the appropriate date. ED sends annual physicals that are due, prior to the start of each month. Nursing keeps a calendar and schedules clients a week earlier than their due date to provide a grace period if a client is to cancel or not show for their scheduled appointment. ED will monitor annual physicals being completed on a monthly basis.
Clients are educated on the importance of attending this annual physical appointment. If they have not been compliant with their scheduled appointment, they will have to wait to see the doctor prior to being dosed that day.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual clinical evaluation with all areas of regulation addressed within the regulatory timeframe in five out of seven applicable records reviewed.
Patient #2 was admitted on October 11, 2022, and was still active at the time of the inspection. An annual physical was due on October 11, 2023; however, there was no documentation in the patient's record of it being completed.
Patient #3 was admitted on June 15, 2023, and was still active at the time of the inspection. An annual physical was due on June 15, 2024; however, there was no documentation in the patient ' s record of it being completed.
Patient #4 was admitted on May 9, 2023, and was still active at the time of the inspection. An annual physical was due on May 9, 2024; however, it was not completed until May 14, 2024.
Patient #6 was admitted on March 8, 2021, and was discharged on May 21, 2024. An annual physical was due on March 8, 2024; however, it was not completed until March 13, 2024.
Patient #8 admitted on January 24, 2023, and was discharged on June 7, 2024. An annual physical was due on January 24, 2024; however, there was no documentation in the patient's record of it being completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 21, 2023 annual licensing inspection.
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Plan of Correction
As of 8/14/2024, clinicians were educated on the importance of completing annual evaluations timely. Clinicians have updated their spreadsheets where they keep these dates organized and readily available to ensure that annual evaluations are completed by due date.
During monthly group clinical supervision, annual evaluations due for the following month will be reviewed to that a plan of action is in place to have them completed.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in six out of seven applicable client records.
Client#1 was admitted on September 8, 2021, and was still active at the time of the inspection. A treatment plan update was completed on November 16, 2023, and the next update was due no later than January 16, 2024; however, the next update was completed on March 21, 2024. The subsequent update was due May 21, 2024; however, the next update was completed on July 9, 2024.
Client #2 was admitted on October 11, 2022, and was still active at the time of the inspection. A treatment plan update was completed on November 10, 2023, and the next update was due no later than January 10, 2024; however, the next update was completed on February 15, 2024. The subsequent update was due on April 15, 2024; however, the next update was completed April 18, 2024.
Client #3 was admitted on June 15, 2023, and was still active at the time of the inspection. A treatment plan update was completed on December 5, 2023, and the next update was due no later than February 5, 2024; however, the next update was completed on April 5, 2024.
Client #4 was admitted on May 9, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 16, 2024, and the next update was due no later than July 16, 2024; however, it was completed until July 25, 2024.
Client #5 was admitted on March 12, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 21, 2024, and the next update was due no later than May 21, 2024; however, it was completed until May 28, 2024
Client #8 was admitted on January 24, 2023, and discharged on June 7, 2024. A treatment plan update was completed on November 10, 2023, and the next update was due no later than January 10, 2024; however, it was completed until February 20, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 8/14/2024, clinicians were educated on the importance of completing treatment plan updates within the appropriate timeframe. Clinicians check their alerts on the EMR daily and put flags in for clients to see them prior to dosing to complete treatment plan updates. ED will monitor through monthly chart audits through the quality department. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to provide a complete patient record, which is to include a discharge summary in one out of three applicable records reviewed. The facility's policy is to complete a discharge summary within seven days of the client's discharge.
Client #8 was admitted on January 24, 2024, and was discharged on June 7, 2024. A discharge summary was due no later than June 14, 2024; however, it was not completed until June 17, 2024.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
ED will send a weekly report of discharge summaries that are due to be submitted. This weekly report includes the client's ID, admission date, discharge date and when the discharge summary is due.
As of 8/10/2024, ED reviews selected charts to check to ensure the discharge summary is completed.
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