This report is a result of an on-site licensure renewal inspection, buprenorphine, and methadone monitoring inspection conducted on October 5-6, 2015 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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Observations
Based on the review of personnel records, the facility failed to document that staff persons received least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in one of three personnel records.
The findings include:
Seven personnel records were reviewed on October 5-6, 2015. Three personnel records were reviewed for the completion of at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. There was no documentation in personnel record # 7 of the completion of the training.
Employee # 7 was hired as a counselor on February 14, 2014. The 4 hours of STD/TB training was to be completed by February 14, 2015. The employee attended 4 hours of STD/TB training that was presented by an outside organization. There was no documentation that the training curriculum used was approved by the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will attend required trainings that have been approved by the Department, within the required timeframes and receive supporting documentation of participation.
The staff identified will re-take the STD/TB training that is Department approved as soon as one is conveniently offered.
Attendance to and documentation of trainings will be monitored quarterly by HR coordinator and Program Manager to ensure compliance. |
Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment, 1 hour of which shall be individual psychotherapy, in 5 of 9 patient records.
The findings include:
Twelve patient records were reviewed October 5-6, 2015. Nine patient records were reviewed for psychotherapy hours during the first year of treatment, including 1 hour of individual psychotherapy. There was no documentation of an average of 2.5 hours and/or 1 hour of individual psychotherapy in patient records # 1, 2, 9, 10 and 12.
Patient #1 was a transfer in and was admitted on June 4, 2015. The patient required an average of 2.5 hours of psychotherapy per month. The patient received 1.25 hours in July, .50 hours in August and 2.5 hours in September, 2015 for an average of 1.42 hours per month. The patient received only .50 hours of individual psychotherapy hours in August, 2015.
Patient # 2 was a transfer in and was admitted on May 15, 2015. The patient required an average of 2.5 hours of psychotherapy per month. The patient received 0 hours in July, 1.25 hours in August and 2.5 hours in September, 2015 for an average of 1.25 hours per month. The patient did not receive any individual psychotherapy hours in July or August, 2015.
Patient # 9 was admitted on May 14, 2015 and was discharged on September 8, 2015. The patient required an average of 2.5 hours of psychotherapy per month. The patient received 1.25 hours in June, 2.50 hours in July and 0 hours in August, 2015 for an average of 1.25 hours per month.
Patient # 10 was admitted on February 19, 2015 and was discharged on June 18, 2015. The patient required an average of 2.5 hours of psychotherapy per month. The patient received 0 hours in March, 1.25 hours in April and 1.25 hours in May, 2015 for an average of .833 hours per month.
Patient # 12 was admitted on April 23, 2015 and was discharged on October 2, 2015. The patient required an average of 2.5 hours of psychotherapy per month. The patient received 1.25 hours in July, 2.50 hours in August and 1.25 hours in September, 2015 for an average of 1.66 hours per month. The patient did not receive any individual psychotherapy hours in August, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Three of the identified clients are discharged so no intervention can be made. The other two identified clients have been placed on behavior contract by their respective counselor that specifically outlines their psychotherapy requirement and the expectation of compliance.
Counselors will maintain a weekly therapy tracking grid for all of their clients.
Tracking grids will be reviewed during clinical meeting every 14 days.
Clients not on track with meeting therapy hours will receive reminder calls of their appointment, be reminded again during check-in, and will have soft holds placed in effort to meet with their counselor.
Compliance of the above will be monitored by the Program Manager monthly during supervision with counselors. |