INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, with the inspection also conducted for the approval to use Methadone and Buprenorphine in the treatment of narcotic addiction. Based on the findings of the on-site inspection, Foundations Medical Services 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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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
The project director failed to have a comprehensive staff development program for agency personnel including policies and procedures for the program on an overall basis.
There was no overall comprehensive staff development program documented for agency personnel at the program.
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Plan of Correction
The Human Resources Coordinator will develop a Comprehensive policy for Staff Development by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff by Human Resources with a receipt acknowledgement attached that staff will sign off on. Full implementation of the policy will occur by September 15, 2019. Program Director will develop a comprehensive training plan for each staff annually by December that is based on identified needs from the individual training plans completed by staff by October 1, 2019. Program Director will submit training plan to Human Resources by December 15th each year. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and time frames for completion of assessment of staff training needs overall.
There was no facility staff development program for agency personnel including policies and procedures for the program indicating who is responsible and time frames for completion of staff training needs overall documented at the program.
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Plan of Correction
The project will develop and approve a Comprehensive policy for Staff Development that will included who is responsible and time frames for completion of assessment of staff training needs overall by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. Program Director will develop a comprehensive training plan for staff annually in December that is based on identified needs from the individual training plans completed by staff by October 1, 2019. Program Director will submit training plan to Human Resources by December 15th each year. HR coordinator will be responsible to ensure the Assessment of staff training needs is completed on time and available. HR coordinator will review staff records annually to ensure compliance. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an overall plan addressing these staff needs.
There was no comprehensive staff development program for agency personnel including policies and procedures documented for the program indicating who is responsible and the time frames for completion of an overall plan addressing staff needs.
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Plan of Correction
The project will develop and approve a Comprehensive policy for Staff Development including who is responsible and the time frames for completion of an overall plan addressing staff needs by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. The Executive Director will be responsible for ensuring a plan to address staff needs is developed for each staff member annually in accordance to the timeframes identified in the policy. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The project director failed to develop a comprehensive staff development program for agency personnel as a whole to include policies and procedures for the program indicating who is responsible and the time frames for completion and a mechanism to collect feedback on this this completed training.
There was no comprehensive staff development program for agency personnel as a whole to include policies and procedures for the program indicating who is responsible and the time frames for completion and a mechanism to collect feedback on this this completed training documented at the program.
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Plan of Correction
The project's current policy addresses who is responsible and the time frames for completion. The Director of Human Resources will develop and approve a Comprehensive policy for Staff Development including identification of where the staff feedback will be stored and how it will be utilized to assess overall training completed by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. Human Resources Coordinator will ensure feedback for all training completed becomes part of the employee record. These records will be reviewed for compliance annually by the Human Resource Coordinator. Director of Human Resources will review completed training and feedback and develop a comprehensive evaluation annually by March 1 of each year. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan.
There was no comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan documented at the program.
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Plan of Correction
The project will develop and approve a Comprehensive policy for Staff Development including the time frames for completion of an overall evaluation of the staff development programs, including negative and positive conclusions by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. The Director of Human Resources will be responsible for the completion of the evaluation and will ensure it is completed by March of every year. Overall compliance of completion will be monitored by the VP of Human Resources. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
During a physical site inspection on July 11, 2019, the facility failed to have hot water temperatures that did not exceed 120 degrees Fahrenheit.
The water temperature in all bathrooms had a temperature reading of 130 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Water temperature at Foundations Medical Services was found to exceed 120 degrees Fahrenheit during a physical site inspection on 07/11/19. Executive Director contacted Maintenance Supervisor on 07/12/19 to reduce the water heater temperature setting to no higher than 120 degrees Fahrenheit. Maintenance completed this task on 07/17/19.
Moving forward, Maintenance Supervisor will add water temperature inspections to the monthly inspections and drills log, effective 08/01/19. Water temperature will be checked on a monthly basis, and temperature setting will be kept at or below 120 degrees Fahrenheit.
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709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of the Policy and Procedures, the project failed to include sex and marital status in the Client Rights policy.709.30 (2), and also the project failed to include documentation of the reasons for removing sections from the record. 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual will be updated by the Policy and procedure committee to include sex and marital status in section 709.30. Chief Compliance Officer will ensure completion of policy by Sept 1, 2019. The program director will be responsible to ensure that the new policy is shared with all staff by Sept 15, 2019.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those 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
During a review of client records on July 11, 2019, the facility failed to notify clients of all their civil rights in seven out of seven records.
Client #1 was admitted on December 8, 2014 and was current at the time of the inspection. Client #1 was not notified that the project may not discriminate in the provision of services on the basis of sex.
Client #2 was admitted on March 31, 2014 and was current at the time of the inspection. Client #2 was not notified that the project may not discriminate in the provision of services on the basis of sex.
Client #3 was admitted on September 12, 2016 and was current at the time of the inspection. Client #3 was not notified that the project may not discriminate in the provision of services on the basis of sex.
Client #4 was admitted on May 28, 2019 and was current at the time of the inspection. Client #4 was not notified that the project may not discriminate in the provision of services on the basis of sex.
Client #5 was admitted on September 23, 2015 and was discharged on May 15, 2019. Client #5 was not notified that the project may not discriminate in the provision of services on the basis of sex.
Client #6 was admitted on September 18, 2018 and was discharged on May 23, 2019. Client #6 was not notified that the project may not discriminate in the provision of services on the basis of sex.
Client #7 was admitted on February 27, 2018 and was discharged on June 3, 2019. Client #7 was not notified that the project may not discriminate in the provision of services on the basis of sex.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In seven of seven charts, Foundations Medical Services was found to have not notified the clients of all their civil rights, specifically that the project may not discriminate in the provision of services on the basis of "sex."
Three of the seven charts reviewed on 07/11/19 were of discharged clients, and so intervention is unable to be completed for these three individuals.
The client handbook, which houses a copy of the client rights, has been updated by the Executive Director of Foundations Medical Services as of 07/30/19 to include that the project will not discriminate in the provision of services on the basis of "age, creed, race, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, religion."
Executive Director and Administrative Assistant will distribute copies of the updated handbook to all active clients with a corresponding signature sheet to verify receipt of the client handbook with updated client rights.
Executive Director will use the facility's Patient List of all active clients to compare and ensure that all clients are provided with a copy and sign the receipt. This will occur no later than 08/16/19. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselors following completion.
Any clients who are in a higher level of care or hospitalized and unavailable to receive this updated client handbook with client rights by 8/16/19 will be presented with a copy and a signature sheet upon return to the facility by their counselor. The completed signature sheets will then be uploaded into each client's ECR and filed in their chart by their counselors.
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