INITIAL COMMENTS
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This report identifies the findings of an on-site complaint investigation conducted at Foundations Medical Services, LLC on January 26 , 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on April 24, 2007.
709.14 Restriction on License (a)(5) Authorized capacity
The facility has a census of 154 for the free-standing outpatient drug free activity which exceeds the authorized maximum capacity of 140.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Outpatient counselor caseloads on various dates, specifically December 29, 2006 and January 5, 2007, exceeded 35 active clients. Two counselors had active client caseloads of 36 and 37 on December 29, 2006 and one counselor had an active client caseload of 37 on January 5, 2007.
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Plan of Correction
Jody Schultz, Interim Program Director, will monitor staff caseloads on a weekly basis to ensure that no staff member has over 35 clients. Currently, we are above the capacity of 140 as we are still attempting to decrease census to be in compliance. Currently, the facility has 4 counselors and 1 counselor assistant. This will be monitored by Jody Schultz, Interim Program Director, weekly. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The fire drill log documentation indicated that no fire drills have taken place since October 2006. All five staff members interviewed during the investigation, could not remember participating in a fire drill since the facility opened on March 30, 2006.
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Plan of Correction
Ed Helms, Maintenance Director, has been conducting random monthly fire drills since the month of February. Proper documentation is completed and filed at the facility. We are in compliance. Compliance will be monitored by Jody Schultz, Interim Program Director, on a monthly basis through file monitoring. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
According to verbal reports by staff members, fire drills have never occurred during the programs hours of operation.
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Plan of Correction
Ed Helms, Maintenance Director, has been conducting random monthly fire drills since the month of February. The March fire drill was conducted during program operations and this will continue. Proper documentation is completed and filed at the facility. We are in compliance. Compliance will be monitored by Jody Schultz, Interim Program Director, on a monthly basis through file monitoring. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The fire drill log did not include all of the required areas. The exit route used, the number of people in the facility at the time of the drill, whether or not the fire alarm or smoke detector was operative and comments on problems encountered during the drill were missing.
There was a previous citation during the November 20-21, 2006 inspection. The plan of correction stated that compliance with this regulation will occur by December 1, 2006. The form has not been corrected.
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Plan of Correction
Ed Helms, Maintenance Director, has been conducting random monthly fire drills since the month of February. Proper documentation (meeting all regulatory standards) is completed and filed at the facility. We are in compliance. Compliance will be monitored by Jody Schultz, Interim Program Director, on a monthly basis through file monitoring. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Documented references for one counselor hired November 2006 included two letters that were dated from 2005, two letters that contained no dates and one letter that was dated by the facility director. The documented references are inconsistent with the date of hire.
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Plan of Correction
Jill Wharrey, Human resource Coordinator, will conduct two reference checks on all prospective candidates prior to hire. Compliance will be current for any hires after April 11, 2007. Compliance will be monitored through annual personnel file monitoring by Jill Wharrey, Human Resource Coordinator. |
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
The facility failed to correct the consent to release information forms which continue to contain the wording "release to/obtain from." In addition, a consent to release information form was signed by the patient and the witness, but it did not list who was receiving the information, what information was to be released, the purpose of the release, an expiration date for the release and whether or not the patient was offered a copy of the release. In essence, the client was allowed to sign a blank consent to release information form. This was not an informed and voluntary consent.
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Plan of Correction
Jody Schultz, Interim Program Director, has revised the "Release of Information" form to meet the listed standards. All staff were trained on completion of the new form. Compliance is current. Compliance will be monitored through monthly chart monitoring by Jody Schultz, Interim Program Director. |
709.30(2) LICENSURE Client Rights
709.30. Client rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
One patient was discriminated against in the provision of services based on his handicap. Treatment must accommodate the physical needs or limitations of patients since the physical plant is accessible to individuals with mobility challenges. During the methadone monitoring visit in October 2006, the Medical Director and Licensing Specialists discussed the need for a wheelchair bound patient to receive 6 day take homes due to pending winter weather. This patient uses a motorized wheelchair to access services. The Department told the program to submit a request for exception for take home privileges for this patient. The program has never submitted this request. The patient was left with no choice but to attempt to traverse an assortment of road conditions to get to the clinic to receive his methadone doses.
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Plan of Correction
Jody Schultz, Interim Program Director, will maintain that accommodations are made as necessary for dosing services of individuals with disabilities. Accommodations will be approved by the DOH, if required. Compliance is current. Compliance will be monitored through weekly staff meetings by Jody Schultz, Interim Program Director. |