INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20-21, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on December 22, 2006.
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The fire drill record did not include all of the required areas. The exit route used, the number of people in the facility at the time of the drill, whether or not the fire alarm or smoke detector was operative, and comments on problems encountered during the drill were missing.
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Plan of Correction
Regulation 705.28 (d) (4) was not in compliance due to a forms issue. The form used did not address several identified areas required in fire dirll reporting. This regualtion will be compliant with regulation 705.28 (d) (4) by December 1, 2006. The Facility Director has completed a new fire drill log form that addresses areas of non complaince in reporting to include the exit route used in each drill with alternating exits from month to month, report if the fire alarm and smoke detectors are in working order, as well as comments that are encountered during the drill and suggestions for improvement. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
The fee for service schedule was not posted.
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Plan of Correction
Standard 709.25 (b) Fiscal Management was shown to be in non compliance as the fee schedule previously posted was removed to make room on the community bulleting to make room for other patient information. This was done in error. This standard was in compliance as of 11/22/2006. The Facility Director was responsible for re-posting the current and accurate fee schedule for services at Foundations. The Facility Director did, in fact, post the fee schedule on the community bulletin board on 11/22/2006. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The written policy on 'duty to warn' issues was not consistent with federal regulation.
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Plan of Correction
Regulation 709.28 (a) (1) Confidentiality was shown to be in non compliance as there was listed in Foundations Policy and Procedure a "duty to warn", which is in direct conflict with state and federal regualtions regarding the confidentiality of patients in drug and alcohol treatment. This regualtion was in compliance as of 11/22/2006 as the Facility Director made necessary changes to Foundations Policy and Procedure as recommended by Licensing Specialist. |
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
The release of information forms do not provide for an informed consent. The standard forms were not being fully or correctly completed before the client was asked to sign the consent. The language "request from" is often indicated as opposed to "release to", which is not consistent with state and federal regulation. The sections of the form reserved for the specific information to be released, the purpose of the release and whether or not the client accepted or refused a copy of the consent were often left blank, rendering the release invalid.
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Plan of Correction
Regulation 709.28 (c) Confidentiality was shown to be out of compliance as the patient's were not given informed consent due to a less than acceptable form. The language "request from" was indicated as opposed to "release to", which is in directo conflict with state and federal regualtion regarding patient confidentiality in a drug and alcohol treatment setting. This standard will be in full and complete compliance by no later than 12/22/2006. Foundations Medical Services will acheive compliance in this area by instituting the folliwng training plan for all clinical staff:
There will be a training conducted by Facility Director and Alicia Fairman, Director of Outpatient Services on 12/5/2006 and 12/20/2006 that will directly adress the new form that gives informed consent for patient as well as the process of properly completing the Release of Information Form. Ongoing compliance will be monitored in follow up trainings to be scheduled ona random basis as well as thorugh independent chart review on a monthly basis. |
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
The treatment plan update in client record #1 failed to include a review of the client's progress in treatment. The treatment plan update was missing for October 2006 in client record #6.
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Plan of Correction
Regualtion 709.92 (b) Treatment and Rehabilitation Services, was shown to be in non compliance as the treatment plan update in record #1 did not document patient progress in treatment goals set forth in comprehensive treatment plan, as well as a missing treatment plan update altogether for patient #6. This regulation will be in full compliance by no later than 12/22/2006. Foundations Medical Services will acheive full compliance in this area by completing the following plan of correction: The Facility Director along with Alicia Fairman, Director of Outpatient Services, will conduct ongoing trainings on December 5, 2006 and December 20, 2006 to adress and review the correct information needed in treatment plan updating. Ongoing compliace will be monitored in the form of cintinued trainings scheduled at intermittent dates to address clinical charting, as well as monthly independent chart review. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Case consultation documentation was missing from client records # 3, 6 and 7.
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Plan of Correction
Regulation 709.93 (a) (10) Client Records; was shown to be in non compliance evidenced by missing case consultation documentation in patient records #3,6 and 7. Foundations Medical Services will acheive full compliance in this area by completing the following plan of correction by no later than 12/22/2006:
The Facility Director along with Alicia Fairman, Director of Outpatient Services, will conduct ongoing trainings on December 5, 2006 and December 20, 2006 to adress and review proper timelines and content involved in case consultation documentation. Ongoing compliace will be monitored in the form of continued trainings scheduled at intermittent dates to address clinical charting, as well as monthly independent chart review. |
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
The discharge summaries in client records # 8, 9 and 10 were consistently missing the reasons for treatment, the services offered and the clients' response to treatment.
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Plan of Correction
Regulation 709.93 (a) (10) Client records; was found to be in non compliance, as discharge summaries in patient record # 8,9,and 10 were missing reasons for treatment, services offered and patient response to treatment due a discharge summary form that fails to review this information and is showm to be non compliant with above cited regulation.
Foundations Medical Services will achieve full compliance in this area by completing the following plan of correction by no later than 12/22/2006:
The Facility Director along with Alicia Fairman, Director of Outpatient Services, will conduct ongoing trainings on December 5, 2006 and December 20, 2006 to adress and review proper timelines and content involved completing the discharge summary. We will also review the new forms in both trainings to ensure compliance with this statute. Ongoing compliace will be monitored in the form of continued trainings scheduled at intermittent dates to address clinical charting, as well as monthly independent chart review.
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