INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6-8, 2014 by staff from the Division of Drug and Alcohol 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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709.28(c) 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:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information from the client prior to the disclosure of information in four of thirteen client records.
The findings include:
Thirteen client records were reviewed on May 6, 7 & 8, 2014. Thirteen client records were required to include an informed and voluntary consent to release information from the client prior to the disclosure of information. Client record # 4, 5, 9 and 10 did not include informed consent.
Record #4 - The client was admitted on December 7, 2013, and was discharged on March 14, 2014. A release of information for a funding source was signed on December 4, 2013, failed to indicate the purpose of the disclosure.
Record #5 - The client was admitted on August 17, 2013, and was discharged on November 26, 2013. A release of information form was signed on August 15, 2013, but failed to indicate the name of the person, agency, or organization to whom disclosure was to be made.
Record #9 - The client was admitted on January 27, 2014. A release of information form was signed on January 27, 2014 for a family healthcare clinic, but failed to indicate the specific information to be disclosed. "Other" was indicated, but was blank. A release of information for a funding source was signed on January 27, 2014, failed to indicate the purpose of the disclosure.
Record #10 - The client was admitted on February 20, 2014. There is a release of information for a family member signed on February 17, 2014, that failed to indicate the specific information to be disclosed, and indicate the purpose of the disclosure.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
In April 2013, the VP of Clinical Services revised all consents to reflect specific information to be disclosed. On May 9, 2014 the Program Director reviewed our intake packet and the release of information with specified information to be disclosed had been replaced in error with an old version that did not specify information to be released. The accurate release was replaced in the intake packets and the old versions were destroyed.
The Program Director met with staff on May 14, 2014 and reviewed the proper completion of consent forms. Staff were instructed to review all records and obtain new releases from clients for any document that had not been completed accurately by June 30,2014.
Program Director will review all consents for compliance with obtaining informed consent prior to disclosure of information on all new admissions until compliance is met for two consecutive months.
Review of completed release of information forms has been added to our monthly open peer chart audit begining in June 2014. The Program Director will monitor monthly peer reviews for compliance with obtaining informed consent prior to disclosure of information as a part of ongoing quality review. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document the provision of treatment services consistent with the type and frequency specified on the treatment plan in six of ten client records.
The findings included;
Thirteen client records were reviewed on May 6, 7, & 8, 2014. Ten client records were required to document the provision of services in accordance with those specified on the treatment plan. Services were not provided as stated on the treatment plan in records # 7, 8, 9, 10, 11 and 13.
Record # 7 - Client was admitted to treatment on January 22, 2014. Services for February 2014, March 2014, and April 2014 were not provided as stated on the treatment plan.
Record # 8 - Client was admitted to treatment on January 29, 2014. Services for February 2014, and April 2014 were not provided as stated on the treatment plan.
Record # 9 - Client was admitted to treatment on January 27, 2014. Services for February 2014, March 2014, and April 2014 were not provided as stated on the treatment plan.
Record # 10 - Client was admitted to treatment on February 20, 2014. Services for March 2014 were not provided as stated on the treatment plan.
Record # 11 - Client was admitted to treatment on November 16, 2013. Services for February 2014, and March 2014 were not provided as stated on the treatment plan.
Record # 13 - Client was admitted to treatment on March 14, 2014. Services for February 2014, March 2014, and April 2014 were not provided as stated on the treatment plan.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
The Program Director reviewed state treatment requirements of 2.5 hours with staff on May 14,2014. Staff were instructed to revise treatment plans to accurately reflect the type and frequency of services to delivered.
Staff were instructed to document outside peer support attendance goals in the recovery plan section of the treatment plan.
The documentation of the type and frequency specified on the treatment plan for on site individual and group treatment hours and off site peer support hours is being added to the monthly open chart review in June 2014. Program Director will monitor the open chart reviews monthly for compliance with documenting the provision of services consistent with the type and frequency specified in the plan.
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