INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18-19, 2008 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 16, 2008.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the administrative information and discussions with the Director on
6-18-08, the facility failed to provide an annual audit for the year ending 2007. The document presented was a fiscal compilation rather than an audit.
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Plan of Correction
The Partners of Foundations Medical Services and the facility manager, Pyramid Healthcare, Inc. will meet in the next 60 days and determine how a cost-effective audit can be achieved that will meet the requirements of licensure for the fiscal 2008 fiscal year.
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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 the review of twelve patient records on 6-18-08 and 6-19-08, the facility failed to protect one patient's identity in one patient record and failed to provide a completed consent to release information form in another patient record. Patient record #2 included a full patient name in another patient's record. Patient record #4 documented a a consent to release information form that did not include a purpose for the disclosure.
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Plan of Correction
All staff will be retrained on the proper use and completion of consent to release information forms. A review of confidentiality procedured will be completed as well. This will be done on July 9, 2008 at an all staff meeting. Any new staff who have not had confidentiality training will be scheduled to do so immediately. The Program Director will ensure that all staff are trained properly. The Program Director will perform a random review of 5 charts per month to ensure these procedures are being followed. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of 12 patient records on 6-19-08, six of those patient records were required to have documented the discharge summaries. The facility failed to include the reason for treatment, and the services offered on the discharge summaries in four of six patient records where required, specifically patient records # 7, 8, 9 and 11.
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Plan of Correction
Effective 7/2/08 a new discharge summary was implemented. This summary includes the initial assessment which will indicate the reason the client entered treatment as well as other demographic information. The initial diagnosis will be indicated. The clients progress in treatment will be documented to include their level of participation, progress on treatment plans, family involvement, referrals, etc. A final assessment will document the clients status at discharge to include prognosis and type of discharge. A discharge diagnosis will be noted and and aftercare plans or referrals. The staff were all trained on July 2, 2008. The Program Director will monitor for compliance by reviewing 5 random charts per month. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on the review of twelve patient records on 6-18-08 and 6-19-08, two patient records were required to have the physician's signature on treatment plans. The physician signature was missing from the treatment plans in two of two patient records where required, specifically patient records #2 and 4.
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Plan of Correction
Effective July 7, 2008 a Physician Signature line was added to the preliminary treatment plan, comprehensive treatment plan and treatment plan update. All staff were notified that a physician signature is required. These will be obtained by the therapist from the physician upon completion of the plan. The Program Director will do a random review of 5 charts monthly to monitor for compliance. |