INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4-5, 2013 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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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the policy and procedure manual and the documentation of the staff development program, the facility failed to follow the time frames outlined in the policies and procedures.
The findings include:
On June 4-5, 2013, a review was completed of the policy and procedure of the staff development program, and the documentation of the assessment of staff training needs, an overall plan for addressing these needs, and an annual evaluation of the overall training plan. The facility practice does not comply with the time frames outlined in the policy and procedure.
The findings were reviewed with the Director of Narcotic Treatment Programs and the facility director and were not disputed.
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Plan of Correction
VP of HR will revise the staff development program policy that outlines the overall plan for addressing needs and an annual evaluation of the overall training plan so that it is congruent with current practice and timeframes.
Revised policy will be distributed to all programs and maintained in the corporate HR manual upon approval of the CEO. |
704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
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Observations
Based on a review of the personnel records on June 4, 2013, the facility staffing requirements facility summary report, and the active patient to counselor caseload list presented by the facility on June 5, 2013, the facility failed to determine when the counselor assistant was eligible for a caseload.
The findings include:
Employee # 4 was hired as a counselor assistant on May 15, 2013. Employee # 4 qualifies under the high school diploma or General Education Development (GED) equivalent, and is required to have three months of direct observation, and nine months of close supervision. The counselor assistant is not eligible for a caseload during the three months of direct observation. The counselor assistant is in the direct observation period from May 2013 to August 2013. Documentation provided by the facility via the facility staffing requirements facility summary report, and the active patient to counselor caseload list indicates the counselor assistant has a caseload of 14 clients.
The findings were reviewed with Director of Narcotic Treatment Programs and the facility director and were not disputed.
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Plan of Correction
On June 6, 2013, the Program Director reassigned employee #4 clients to other program counselors ensuring client to staff ratio was maintained.
Clients will not be assigned to Employee #4 until a positive assessment has been achieved outlining her abilities to handle a caseload and after the 90 day direct observation period which will be August 14, 2013. |
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 the patient records, the facility failed to document consent to release information forms which identified the specific information to be disclosed and/or the purpose of the disclosure in five of nine patient records.
The findings include:
Eleven patient records were reviewed on June 5, 2013. Nine patient records were reviewed for release of information forms. Five of the patient records, # 1, 2, 7, 8, and 11, included consent to release information forms that did not indicate what specific information was to be disclosed and/or the purpose of the disclosure.
Client # 1 was admitted to treatment on January 24, 2013 and discharged on April 8, 2013. A release of information form for an insurance company was signed on January 22, 2013 and did not indicate the purpose of the disclosure. A release of information form for a boyfriend was signed on January 22, 2013 and did not indicate the specific information to be disclosed.
Client # 2 was admitted to treatment on February 1, 2013 and discharged on May 6, 2013. A release of information form for an insurance company was signed on January 31, 2013 and did not indicate the purpose of the disclosure.
Client # 7 was admitted to treatment on February 21, 2013. A release of information form for another treatment provider was signed on February 21, 2013 and did not indicate what specific information was to be disclosed. A release of information form for a parent was signed on February 18, 2013 and did not indicate what specific information was to be disclosed. A release of information form for an insurance company was signed on February 18, 2013 and did not indicate the purpose of the disclosure. A release of information form for a physician was signed on February 27, 2013 and did not indicate the purpose of the disclosure.
Client # 8 was admitted to treatment on February 27, 2013. A release of information form for a parent was signed on February 25, 2013 and did not indicate what specific information was to be disclosed. A release of information form for an insurance company was signed on February 25, 2013 and did not indicate the purpose of the disclosure.
Client # 11 was admitted to treatment on March 11, 2013. A release of information form for a physician was signed on March 11, 2013 and did not indicate what specific information was to be disclosed or the purpose of the disclosure.
The findings were reviewed with the Director of Narcotic Treatment Programs and the facility director and were not disputed.
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Plan of Correction
In April 2013, the VP of Clinical Services revised all consent forms to reflect specific information to be disclosed and purpose for the disclosure. The records pulled by the auditor were prior to the April revision date.
The proper completion of cosent forms was reviewed with staff on June 6, 2013 and a random chart audit confirmed that the proper "revised" consent forms were being used. |