INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 30-June 1, 2012, 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.
|
Plan of Correction
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel records.
The findings include:
Seven personnel records were reviewed on May 30- June 1, 2012. One personnel record pertained to the project director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 was hired on July 1, 1999. The facility training year reviewed was from January 1, 2011 through December 31, 2011. Employee # 1 had no training hours documented for the 2011 training year.
The Director of Narcotic Treatment Programs was interviewed on June 1, 2012 and confirmed the findings.
|
Plan of Correction
Training requirements will be reviewed with the Project Director by the Director of Narcotic Treatment Programs by 6/30/12. Project Director will obtain the annual required training hours and provide documentation of completion of hours to Human Resource Department. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
|
Observations
Based on the review of client records, the client handbook and facility postings, the facility failed to inform the client of the right to appeal the decision limiting access to his/her records to the project director in 12 of 12 client records.
The findings include:
Twenty client records were reviewed on May 30-June 31, 2012. Twelve client records were reviewed for documentation that the client was informed of their rights. The facility did not document the client was informed of the right to appeal the decision limiting access to his/her records to the project director in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12. There was no documentation the client was informed of this right in the clients' record , in the client handbook nor were there posting of the right in the facility.
The Director of Narcotic Treatment Programs was interviewed on June 1, 2012 and confirmed the findings.
|
Plan of Correction
Client Rights had been modified and approved by the Project Director to reflect that the client has the right to appeal the decision limiting access to his/her records to the project director. The modified version was not posted in client area. The Director of Narcotic Treatment Programs posted the correct Client Right's document in the client area on 6/1/12. To ensure clients received new information, the program director will assure each client is provided a copy of the posted revised Client Rights by 7/1/12. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document psychosocial evaluations that included a clinical assessment of the client in five of twelve client records.
The findings include:
Twenty client records were reviewed on May 30-June 1, 2012. Twelve client records required the completion of psychosocial evaluations. Five client records did not include a clinical assessment of the client. The psychosocial evaluations included client reported information or historical information in client records # 1, 5, 8, 9 and 10, but were not evaluative.
Client # 1 was admitted on November 23, 2011. The psychosocial evaluation, completed December 16, 2011 did not include a clinical assessment of the client and included only client reported information.
Client # 5 was admitted on February 24, 2012. There was no documentation that a psychosocial evaluation had been completed.
Client # 8 was admitted on April 13, 2012. There was no documentation that a psychosocial evaluation had been completed.
Client # 9 was admitted on March 29, 2012. There was no documentation that a psychosocial evaluation had been completed.
Client # 10 was admitted on March 15, 2012. There was no documentation that a psychosocial evaluation had been completed.
The Director of Narcotic Treatment Programs was interviewed on June 1, 2012 and confirmed the findings.
|
Plan of Correction
Psychosocial evaluations, which include a clinical assessment of the client, will be completed within 30 days of admission by the counselor. The program director will conduct random monthly chart audits and counselors will participate in monthly peer chart reviews to ensure compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type of treatment and rehabilitation services in four of six client records.
The findings include:
Twenty client records were reviewed on May 30- June 1, 2012. Six client records were reviewed for documentation of an individual treatment and rehabilitation plan. The facility failed to document the type of treatment and rehabilitation services in client records # 1, 2, 3 and 4.
Client # 1 was admitted into treatment on November 23, 2011. An individual treatment and rehabilitation plan was developed with the client on December 19, 2011. The treatment plan did not specify the type of treatment and rehabilitation services.
Client # 2 was admitted into treatment on January 26, 2012. An individual treatment and rehabilitation plan was developed with the client on February 14, 2012. The treatment plan did not specify the type of treatment and rehabilitation services.
Client # 3 was admitted into treatment on August 10, 2011. An individual treatment and rehabilitation plan was developed with the client on September 15, 2011. The treatment plan did not specify the type of treatment and rehabilitation services.
Client # 4 was admitted into treatment on September 1, 2011. An individual treatment and rehabilitation plan was developed with the client on September 25, 2011. The treatment plan did not specify the type of treatment and rehabilitation services.
The Director of Narcotic Treatment Programs was interviewed on June 1, 2012 and confirmed the findings.
|
Plan of Correction
As a Performance Improvement initiative prior to DOH audit, the facility decided to transition back to paper record documentation effective 6/11/12. Specifically, paper treatment plans prompt the counselor to include type and frequency of treatment services. Counselors were trained to the paper forms by the Program Director 5/25/12. Random monthly chart audits conducted by the Program Director will ensure continued compliance. |