INITIAL COMMENTS
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This report is a result of an on-site licensure renewal, methadone monitoring inspection and complaint investigation conducted on July 20-21, 2023, 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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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on five of eight client records reviewed, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights to include the right to inspect their own records, that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and the reasons for removing sections shall be documented in the record in client records # 1, 2, 3, 6, and 8.
Client # 1 was admitted on October 11, 2022 and was still active at the time of the inspection.
Client # 2 was admitted on June 27, 2023 and was still active at the time of the inspection.
Client # 3 was admitted on October 27, 2022 and was still active at the time of the
inspection.
Client # 6 was admitted on March 27, 2023 and was discharged April 13, 2023.
Client # 8 was admitted on May 16, 2023 and was discharged July 3, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client handbook, which houses a copy of the client rights, has been updated by the Regional Leadership team of Pyramid Healthcare and reviewed with the Program Director of Foundations Medical Services as of 08/7/2023 to include that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and the reasons for removing sections shall be documented in the record in client records #1, 2,3,6, and 8.
Program Director and Administrative Assistant will distribute copies of the updated handbook to all active clients with a corresponding signature sheet to verify receipt of the client handbook with updated client rights.
Program Director will use the facility's Patient List of all active clients to compare and ensure that all clients are provided with a copy and sign the receipt. This will occur no later than 08/25/23. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselor's following completion.
Any clients who are in a higher level of care or hospitalized and unavailable to receive this updated client handbook with client rights by 8/25/23 will be presented with a copy and a signature sheet upon return to the facility by their counselor. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselors.
Any clients who are admitted into treatment after 8/7/23, will receive and sign off on the updated client handbook and the updated client rights form in the EMR that the client signs at time of their LOCA.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on five of eight client records reviewed, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights to include the right to appeal a decision limiting access to their records to the director in client records # 1, 2, 3, 6, and 8.
Client # 1 was admitted on October 11, 2022 and was still active at the time of the inspection.
Client # 2 was admitted on June 27, 2023 and was still active at the time of the inspection.
Client # 3 was admitted on October 27, 2022 and was still active at the time of the
inspection.
Client # 6 was admitted on March 27, 2023 and was discharged April 13, 2023.
Client # 8 was admitted on May 16, 2023 and was discharged July 3, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client handbook, which houses a copy of the client rights, has been updated by the Regional Leadership team of Pyramid Healthcare and reviewed with the Program Director of Foundations Medical Services as of 8/7/23 to include that clients have the right to appeal a decision limiting access to their records to the director.
Program Director and Administrative Assistant will distribute copies of the updated handbook to all active clients with a corresponding signature sheet to verify receipt of the client handbook with updated client rights.
The Program Director will use the facility's Patient List of all active clients to compare and ensure that all clients are provided with a copy and sign the receipt. This will occur no later than 08/25/23. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselor's following completion.
Any clients who are in a higher level of care or hospitalized and unavailable to receive this updated client handbook with client rights by 8/25/23 will be presented with a copy and a signature sheet upon return to the facility by their counselor. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselors.
Any client who is admitted into treatment after 8/7/23 will receive and sign off on the updated client handbook and the updated client rights form in the EMR that the client signs at time of their LOCA.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on five of eight client records reviewed, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights to include the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in client records # 1, 2, 3, 6, and 8.
Client # 1 was admitted on October 11, 2022 and was still active at the time of the inspection.
Client # 2 was admitted on June 27, 2023 and was still active at the time of the inspection.
Client # 3 was admitted on October 27, 2022 and was still active at the time of the
inspection.
Client # 6 was admitted on March 27, 2023 and was discharged April 13, 2023.
Client # 8 was admitted on May 16, 2023 and was discharged July 3, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client handbook, which houses a copy of the client rights, has been updated by the Regional Leadership team of Pyramid Healthcare and reviewed with the Program Director of Foundations Medical Services as of 8/7/23 to include that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Program Director and Administrative Assistant will distribute copies of the updated handbook to all active clients with a corresponding signature sheet to verify receipt of the client handbook with updated client rights.
The Program Director will use the facility's Patient List of all active clients to compare and ensure that all clients are provided with a copy and sign the receipt. This will occur no later than 08/25/23. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselor's following completion.
Any clients who are in a higher level of care or hospitalized and unavailable to receive this updated client handbook with client rights by 8/25/23 will be presented with a copy and a signature sheet upon return to the facility by their counselor. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselors.
Any client who is admitted into treatment after 8/7/23 will receive and sign off on the updated client handbook and the updated client rights form in the EMR that the client signs at time of their LOCA.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on five of eight client records reviewed, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights to include the right to submit rebuttal data or memoranda to their own records in client records # 1, 2, 3, 6, and 8.
Client # 1 was admitted on October 11, 2022 and was still active at the time of the inspection.
Client # 2 was admitted on June 27, 2023 and was still active at the time of the inspection.
Client # 3 was admitted on October 27, 2022 and was still active at the time of the
inspection.
Client # 6 was admitted on March 27, 2023 and was discharged April 13, 2023.
Client # 8 was admitted on May 16, 2023 and was discharged July 3, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client handbook, which houses a copy of the client rights, has been updated by the Regional Leadership team of Pyramid Healthcare and reviewed with the Program Director of Foundations Medical Services as of 8/7/23 to include that clients have the right to submit rebuttal data or memoranda to their own records.
Program Director and Administrative Assistant will distribute copies of the updated handbook to all active clients with a corresponding signature sheet to verify receipt of the client handbook with updated client rights.
The Program Director will use the facility's Patient List of all active clients to compare and ensure that all clients are provided with a copy and sign the receipt. This will occur no later than 08/25/23. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselor's following completion.
Any clients who are in a higher level of care or hospitalized and unavailable to receive this updated client handbook with client rights by 8/25/23 will be presented with a copy and a signature sheet upon return to the facility by their counselor. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselors.
Any client who is admitted into treatment after 8/7/23 will receive and sign off on the updated client handbook and the updated client rights form in the EMR that the client signs at time of their LOCA.
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715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
Based on a review of the facility ' s written policies and procedures relating to granting and rescinding take-home medication privileges, the facility failed to update their policy.
The facility ' s policy states, " all patients shall come to the clinic for observation for a minimum of 6 days a week for at least 90 days unless otherwise approved under state exception. " The facility has not been open six days a week in 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
With the Physician Approval, the Program Director submitted an exception to be closed on Saturdays due to having a nurse shortage. DDAP accepted the exception request allowing the facility to be closed on Saturdays from July 31, 2023- December 31, 2023 and to provide all clients with a Saturday take home bottle exception. During this exception time frame, Foundations will hire and train additional nursing staff to comply with the dispensing ratio and to provide adequate nursing coverage 6 days per week. All clients have been notified of the change on Monday July, 31, 2023. After December 31, 2023, the facility will resume to offering programing and services 6 days a week.
In review of our facility policy, it currently captures several "factors" on how take home decisions are determined. Additionally, the policy further highlights considerations that the NTP Physician will use. The current policy contains these pieces, in addition to the pursuit of an approval by the state, which should cover all of the needs. The policy captures the 6 days a week, "unless otherwise approved under state exception." The facility received the approval and now remains in compliance with our referenced policy. We will continue to review our policies as changes present themselves in the future and should Foundations be unable to hire staff prior to the approval from the Department ending, we will be sure to seek an extension to the exception with the Department.
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on one of one applicable patient record reviewed, the facility failed to include the patient psychosocial summary in the transfer paperwork provided to the receiving facility in patient record # 8.
Patient # 8 was admitted on May 16, 2023 and discharged on July 3, 2023. Patient # 8 was transferred to another facility and the documented transfer paperwork did not include the psychosocial summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 8/7/2023 Foundations Medical Services will ensure adherence to the Patient Transfer policy regarding all clients seeking transfer to an external narcotic treatment program. Program Director will ensure that all requested documentation is submitted to the transferring facility within 7 days of reception. In order to ensure compliance with the 7-day requirement, the program will fax all information and retain of copy of the fax transmittal with proper date and time of submission. If fax is not possible, the program will arrange for overnight mail. All shared information, including received fax transmittal, will be saved in the client's clinical record for potential reference at a later time.
Every week the Program Director will be reviewing the document library of clients charts of those clients who transferred to another clinic to ensure all documentation was submitted and uploaded. As of 8/2/23, Program Director has reviewed the policy and process for patient transfers to external narcotic treatment programs with all staff during the team meeting.
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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 one of three applicable patient records reviewed, the facility failed to provide documentation of an annual evaluation of each patient 's status completed by the patient's counselor and reviewed, dated, and signed by the medical director in patient record # 4.
Patient # 4 was admitted on April 1, 2022 and was still active at the time of the inspection. There was not an annual evaluation documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 8/7/2023, Counselors will ensure to forward all annual evaluations to the Medical Director and Program Director only for signature. The Program Director will review all clinical documentation during monthly clinical supervision and facilitate open chart reviews. The Program Directors findings will be reported within a supervision note. Supervision notes will be signed off by the employee and the program director and kept on site. In addition, the team will review regulations concerning patient annuals reviews. Within this meeting, the team will discuss proper notification of staff, requirements for review and signature, and regulatory timeframes. This review will occur within the following team meeting on 8/2/23.
Compliance will be monitored by the PD who will review all supervision notes monthly and then submit them to clinical compliance officers for additional review.
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