INITIAL COMMENTS
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This report is a result of an on-site methadone monitoring and licensure renewal inspection conducted on September 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Foundation Medical Services 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection, the facility failed to ensure counseling sessions could not been seen outside the counseling room.
The counselor's offices had narrow windows panels on the door. There were no coverings on the windows, allowing clients to be seen by individuals outside of the counseling offices.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director wants to ensure all clients have privacy during their counseling sessions and to make sure all their patients' rights are protected through confidentiality. With receiving this deficiency, the plan of correction is for all counselors to put protective covering over their door windows to ensure the privacy of their clients. This was completed immediately after Foundations Medical Services received their survey from DDAP on 9/7/2021. The Program Director will continue to monitor and make sure that the windows are covered all the time. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the physical plant inspection, the facility failed to ventilate the bathroom by an exhaust fan or window.
The client's bathroom that is used to collect urine specimens did not have an operable exhaust fan or window.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director immediately notified the maintence department to make sure the exhaust fan was fixed in the specimens' bathroom. Maintence came onsite to Foundations Medical Services on 9/8/2021 to fix the exhaust fan. The exhaust fan is working in the specimens' bathroom and both the maintence department and Program Director will check on the fan during monthly building inspections to ensure everything is working properly. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of patient records, the facility failed to verify the individual had reached the age of 18, in one of five records.
Patient # 2 was admitted on March 1, 2021 and was still an active patient at the time of the inspection. There was no documentation that verified the patient had reached the age of 18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed with all staff members the Licensing Alert 01-2018 which explains how to screen each individual to determine eligibility for admission during the team debriefing meeting on 9/8/2021 after the completion of the DDAP Survey on 9/7/2021. The Program Director reviewed all acceptable identifications to verify the patient's identity which is listed in the 28 pa. Code 715.9.Intake. To ensure that each patient has proper verification of age, the Program Director will be reviewing all new patients' charts on a monthly basis. Also, both the counselors and medical stuff will be conducting peer audits to review charts on a monthly basis to ensure all clients (new and old) have proper identification verification. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the individual's identity which included name, address, date of birth and other identifying information, in one of five records.
Patient # 2 was admitted on March 1, 2021 and was still an active patient at the time of the inspection. There was no documentation that verified the individual's identity which included name, address, date of birth and other identifying information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the policy and regulation with all staff on 9/13/2021 detailing the verification requirements. The Policy Numbered 715.13 of Pyramid Healthcare, Inc. states that a patient may use a utility bill with the correct name and current address, a medical card with a photo ID, or a lease/mortgage contract to prove their name, address, and identifying information. To provide proof of age, patients and staff are required to follow the 715.9 NTP policy and plan of correction previously addressed on age verification. Foundations Medical Services Administrative Assistant will be responsible for updating all identification of all patients who need to be updated and be responsible in ensuring all patients have proper identification that proves their name, DOB, address, and identifying information. During the patient's level of care assessment, the counselor will be responsible for double checking that the patient has proper identification and the medical staff will also check during the admission process. Proper identification and documentation will then be reviewed regularly during peer monthly chart audits to ensure the facility has all updated information on the patient. |