INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 5, 2022 - October 6, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of 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
|
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director wants to ensure all clients have privacy during their group counseling sessions to ensure all their patients' rights are protected through confidentiality but to also ensure the safety of all staff and clients. With receiving this deficiency, the plan of correction is to disconnect the cameras that are in the group rooms so no footage is being recorded until the facility receives an approval from DDAP for an exception to have the cameras for safety measures. On 10/7/2022, an exception letter was submitted to DDAP explaining how Foundations would like approval to have cameras installed in the main group rooms to increase security measures for both the client's serves and staff facilitating services. The main group rooms are located within a separate wing of the building creating a barrier for quick intervention when needed. The addition of cameras would allow for surveillance of needs and permit a safer environment for clients and staff when participating in group services. Camera surveillance would not include audio. All clients will also be informed of the cameras during basic orientation to the program. Camera footage will only be reviewed in instances where situations arise that have potential to result in incident reporting. The cameras in the group rooms will remain off till Foundations Medical Services receive verification that the exception letter has been accepted. If DDAP denies the exception, the cameras will be removed immediately in their entirety in the group rooms. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The last inspection was September 21, 2021.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director immediately notified the maintence department to stress the importance of making sure the fire extinguishers are inspected and approved by the local fire department or Fire Extinguisher Company on a yearly basis. Maintence reported that the fire department will be onsite to inspect all fire extinguishers on 10/13/2022. To prevent this deficiency from happing again, the Program Director and maintence team together will check the fire extinguishers during the monthly building inspection walk-throughs, and a month prior to expiration, contact the fire department to come to the facility for the inspection. This will ensure that every year the fire extinguishers remain in compliance of the regulation standard. |