INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 16, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Foundations Medical Services Inc. was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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Plan of Correction
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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.
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Observations
While conducting the complaint investigation on December 16, 2019, the facility failed for ensure that counseling could not be heard. During the complaint investigation a counseling office located next to the office of the investigation, counseling was being conducted and could be heard.
These finding were reviewed with the facility director during the investigation.
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Plan of Correction
Consequent to meeting with DDAP investigator on 12/16/2019, Program Director placed sound machines outside each counseling office immediately to protect client confidentiality. On 12/17/19 staff were informed of the importance in using such devices while in session in order to ensure client confidentiality. Sound machines were put into place immediately for all 12/17/2019 sessions. On 1/2/20, the facility has since placed an order for improved sound machines that are wall-mountable. Program Director will conduct daily walk-throughs to ensure that sound machines are being utilized. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client #2's treatment plan dated 8/26/19 under " Therapeutic relationship" states the client is only scheduling session for an hour, however with his lapse his counseling hours need to be increased. Then on the treatment plan dated 10/23/19 the statement is states the same as what was documented on treatment plan 8/26/19 and there was no increase in treatment hours between the two treatment plans.
These finding were reviewed with the facility director during the investigation.
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Plan of Correction
On 12/17/2019, Program Director met with clinician regarding the discrepancy between treatment plan statement and counseling hours. Counselor to assess clients' needs for therapy and make further recommendation within upcoming treatment plans. The Program Director will review and sign off on all active treatment plans in order to ensure compliance in clinical recommendations. Program Director will conduct chart audits at least every other month. Concerns including but not limited to treatment planning and counseling attendance hours will be addressed within individual supervision |