INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20 - 21, 2007 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 and a plan of correction is due on September 21, 2007.
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant tour on August 20, 2007, and an interview with the Administrator on August 20, 2007, it was determined that the facility failed to obtain a current inspection for the fire extinguishers. Three of the three fire extinguishers in the building were expired. One fire extinguisher at the front entrance and one fire extinguisher in the electrical room were inspected in February 2006, and therefore expired at the end of February 2007. The third fire extinguishers in the hallway was inspected in January 2006 and therefore expired at the end of January 2007.
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Plan of Correction
PFE Fire Safety Corporation was at Foundations on 8/23/2007 and inspected the extinguishers and replaced the old tags. Foundations Medical Services has been put on an annual inspections rotation every August for an inspection of the 3 Fire extinguishers at the facility |
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 seven client records it was determined that the facility failed to obtain an informed consent prior to the disclosure of information. Two client records (#1, #3) did not have documentation of the written consents to release information. Documentation in client record #1 indicated that information had been disclosed without a signed written consent to release information. Client record #3 included a letter addressed "To whom it may concern", but there was no identifying agency or person to whom the letter was sent, and therefore, no corresponding release of information.
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Plan of Correction
Date of Compliance Immediately
Methodology Director went over the proper way to complete consents after the site visit. Charts will be reviewed weekly by staff abd director to make sure that consents are done properly. When new staff are hired director will have a training on the proper way to write consents. All forms are reviewed with all new staff by directorthe first week of their employment.
Person responsible- The Facility Director is responsible for compliance
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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 the review four client records it was determined that the facility failed to include new goals and objectives on the treatment plan updates. Three of the four clinical records reviewed were missing revised goals and objectives as part of the treatment plan update.
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Plan of Correction
Date of Compliance-Immediately-by the next treatment plan update in the chart
Methodology-All treatment plans will have new goals and objectives. director will monitor all treatment plan updates to maintain compliance in this area.
Person Responsible- The facility director is responsible for treatment plan compliance |