INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15 through June 17, 2010 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 and a plan of correction is due on July 11, 2010.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel training records and an interview with the facility director and HR personnel, the facility failed to provide documentation of TB/STD training in one of seven personnel training records, as required by regulation.
The findings include:
Seven personnel training records were reviewed on June 15 and 16, 2010. Six personnel training records were required to have documentation of TB/STD training. In accordance with the regulations, staff persons shall receive a minimum of 4 hours of TB/STD training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training with the first 2 years of employment. The facility did not provide documentation of TB/STD training in personnel training record #5,
Employee # 5 was originally hired on 7/1/07 as support staff and was promoted to counselor assistant on 1/25/10. TB/STD training was due to be completed no later than July 1, 2009. The facility failed to provide documentation of TB/STD training An interview with HR personnel confirmed that TB/STD training had not been completed.
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Plan of Correction
Employee # 5 is scheduled for TB/STD training in October being provided by Pyramid Healthcare Inc. This is still pending BDAP approval. Therefore, HR will search for a backup option and keep available. HR will ensure this is completed by 10/31/10. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures and an interview with the facility director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24 hour emergency medical coverage.
The findings include:
The administrative policies and procedures were reviewed on June 15, 2010. Although the facility had a referral agreement with a local hospital, the referral agreement did not specifically state that is was for 24 hour medical coverage. This was confirmed with the facility director on June 15, 2010.
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Plan of Correction
Program Director will send out a new specific referral agreement to Butler Memorial Hospital to have returned within 90 days. This will be sent out by 7/23/10. |
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
Based on a review of administrative policy and procedures, client records and an interview with the facility director, the facility failed to document a review and/or updates of treatment plan updates in three or five client records.
The findings include:
Eight client records were reviewed on June 16 and 17, 2010. Five of the client records were required to have treatment plan updates. In accordance with facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 14, 15, and 20.
In client record #14, the client was admitted on March 11, 2010. The comprehensive treatment plan did not document the date the treatment plan was completed; it could not be determined when the treatment plan updates were completed.
In client record # 15, the client was admitted on November 3, 2009. The comprehensive treatment plan was completed on January 5, 2010. The first treatment plan update was due no later than March 5, 2010; it was not completed until March 23, 2010. The second treatment plan update was due no later then May 5, 2010; it was not completed until May 13, 2010. The facility failed to document the completion of the treatment plan updates and review of progress in accordance with the facility policy and procedure.
In client record #20, the client was admitted June 6, 2009. The comprehensive treatment plan was completed on July 7, 2009. The first treatment plan update was completed on September 9, 2009. The client was discharged on May 6, 2010. Between September 9, 2009 and May 6, 2010, there was no documentation of treatment plan updates in the client record.
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Plan of Correction
Clinical Coordinator will provide a series of trainings to staff at Foundations on proper documentation of treatment plans and treatment plan updates. These will be completed by 9/1/10. Program Director will monitor charts monthly to ensure completion of treatment plans and treatment plan updates. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document follow-up attempts in three of four client records.
The findings include:
Eight client records were reviewed on June 16 and 17, 2010. Four of the eight client records were required to document follow-up attempts. Client records # 17, 18, and 19 did not contain documentation of follow-up attempts.
Record # 17 was admitted on 8/12/09 and discharged on 4/12/10. The follow up attempt was due on 5/12/10.
Record # 18 was admitted on 3/6/09 and discharged on 2/19/10. The follow up attempt was due on 3/19/10.
Record # 19 was admitted on 12/7/09 and discharged on 1/16/10. The follow up attempt was due on 2/16/10.
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Plan of Correction
Program Director will review the follow up procedure with staff. A new process on verification of this procedure will be implemented by 7/30/10 Chart monitors by the Program Director will be performed on all closed charts within 14 days to ensure ongoing compliance. |