INITIAL COMMENTS
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This report is a result of an on-site inspection conducted as a follow-up to a letter of Intent that was issued following an unannounced complaint investigation on 7/18/2008. This inspection was conducted on November 4, 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. Deficiencies were identified during this inspection and a plan of correction is due on December 23, 2008.
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Plan of Correction
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the facility failed to provide 2.5 hours of psychotherapy in two of nine patient records.
The findings include:
Thirteen patient records were reviewed on November 4, 2008. Psychotherapy content was reviewed in nine records. The facility failed to provide patients # 2 and 3 with the required minimum of 2.5 hours of psychotherapy each month, specifically both patients had only 1.25 hours of documented hours of therapy for the month of October, 2008.
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Plan of Correction
Counselors have increased their documentation of attempts at engaging clients in treatment, consistency with communicating expectations to clients regarding attendance, holding clients accountable for missing sessions and implementing treatment plans for clients whose attendance has become a treatment issue. Counselors are making attempts to reschedule cancelled sessions within 1-2 weeks of the cancellation. Program director continues to monitor client hours weekly by counselor. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure that all annual evaluations were completed as required.
The findings include:
Thirteen records were revewed on November 4, 2008. Annual evaluations were required in four patient records. The facility failed to provide documentation of an annual evaluation for patient # 3 that was due October 2008.
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Plan of Correction
A chart monitor tracking log has been implemented. The counselor enters the admit date and this tool automatically generates the due date for the psychosocial, treatment plan updates, case consults, and annual reviews/physicals. Upon completion of entering the data the counselor submits the chart to the program director who utilizes this chart on a weekly basis to monitor what is due. The program director then request to review the documentation with the counselor to ensure that all signatures have been obtained and the forms have been completed within the appropriate time frame.
The Program Director will also monitor for compliance by reviewing 5 random charts per month.
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