INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Foster Hill Wellness, 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:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on two of six personnel records reviewed, the facility failed to provide documentation of at least one year of clinical experience with a qualifying bachelor's degree.Employee # 4 was hired as a counselor assistant on November 18, 2019 and promoted to a counselor position on January 4, 2020. After a review of the employee's resume, there was no documentation of at least one year of clinical experience.Employee # 5 was hired as a counselor on September 14, 2020. After a review of the employee's resume, there was no documentation of at least one year of clinical experience.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Foster Hill Wellness LLC will ensure that all counselors meet one year of clinical experience training by verifying with their previous employer that any clinical experience noted in the candidate's resume took place and qualifies as clinical care. The Chief Operation Officer, (COO) will review all resumes and contact prior treatment centers to verify the resume and candidates.
# 4 This employee at this time has received over a year of clinical experience with a supervisor at our facility and is now eligible for promotion as a counselor.
# 5 This employee had a role as case manager of human services with a four year degree and provided one on one counseling was provided in Mental Health. This was considered behavioral health clinical experience at the time of hire. Foster Hill will place this employee in the position of counselor's assistant immediately until they have over one year of supervised clinical with a full-time qualified counselor experience at our facility.
The Chief Operating Officer will ensure that these plans are implemented and documented according to licensing requirements.
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of one of one counselor assistant positions, the facility failed to provide documentation of supervision notes being provided by a full-time clinical supervisor or qualifying counselor. Employee # 6 was originally hired as a support staff on June 6, 2019 and promoted to a counselor assistant position on August 10, 2020. There was no documentation of supervision provided in the employee record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A full-time qualified counselor will complete weekly notes on supervision in a typed format rather than handwritten format and provide counselor assistant supervision in accordance with the licensing alert of October 2002. The COO will review that all supervision takes place as required.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, a sidewalk that connected between the male cabins was ice and snow covered and was not able to be safely walked navigated.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Snow and ice were cleared immediately after the DDAP inspection, verified by the COO. Daily inspection of the property will take place during any snow, ice, or water weather event that may affect surrounding client pathways. Hazardous surfaces will be cleared of snow/ice by maintenance staff promptly as needed and all walkways and roadways will be kept in good repair.
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705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. The building named "Boathouse" has two offices that each are only accessible by exterior doors. Neither office had a fire extinguisher. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Extinguishers were placed on both sides of the "boathouse" office. They are tagged inspected by Sussex Fire Company and they will remain in that location. This was verified by the COO of Foster Hill Wellness, LLC. The COO will ensure that inspections of each building are completed at least quarterly to ensure the proper number of fire extinguishers are installed and that inspections are current. |
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.
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Observations
Based on four of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Client # 4 was admitted on February 5, 2021 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes. Client # 5 was admitted on May 1, 2020 and was discharged on July 31, 2020. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes. Client # 6 was admitted on September 15, 2020 and was discharged on November 1, 2020. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes. Client # 7 was admitted on September 8, 2020 and was discharged on November 7, 2020. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Clinical supervisor will review releases to ensure all consents. In order to ensure that this deficiency does not occur again staff will be re-trained on client confidentiality. The COO, clinical supervisor or lead counselor will complete weekly record checks to ensure that consents to release information are documented prior to any disclosures of client identifying information. The training will be completed within 30 days and record checks will begin at once.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on one of seven client records reviewed, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 1.Client # 1 was admitted on November 30, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on November 30, 2020 to a court advocate allowed for the release of treatment plans, discharge summary, and aftercare plan. Also, to a funding agency allowed treatment plans, psychological history and assessment, physical, medical history, Biopsychosocial, labs, employment information, legal status, family information, discharge summary, and aftercare plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-trained on the requirements of 4 Pa. Code 255.5. The COO, clinical supervisor or lead counselor will complete weekly checks of consents to release information as well as the disclosures made in the client records to ensure that a consent to release information is documented prior to the release of any client identifying information and that information released does not exceed the limits imposed by 4 Pa. Code 255.5. The training will be completed within 30 days and record checks will begin at once.
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709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of the acknowledgement that the client was informed of the criteria for admission, treatment, completion and discharge in client records # 1, 2, 3, 4, 5, 6, 7. Client # 1 was admitted on November 30, 2020 and was still active at the time of the inspection. There was no documentation the client was informed of criteria for admission, treatment, completion, and discharge in the client record. Client # 2 was admitted on November 2, 2020 and was still active at the time of the inspection. There was no documentation the client was informed of criteria for admission, treatment, completion, and discharge in the client record. Client # 3 was admitted on December 11, 2020 and was still active at the time of the inspection. There was no documentation the client was informed of criteria for admission, treatment, completion, and discharge in the client record. Client # 4 was admitted on February 5, 2021 and was still active at the time of the inspection. There was no documentation the client was informed of criteria for admission, treatment, completion, and discharge in the client record. Client # 5 was admitted on May 1, 2020 and was discharged on July 31, 2020. There was no documentation the client was informed of criteria for admission, treatment, completion, and discharge in the client record. Client # 6 was admitted on September 15, 2020 and was discharged on November 1, 2020. There was no documentation the client was informed of criteria for admission, treatment, completion, and discharge in the client record. Client # 7 was admitted on September 8, 2020 and was discharged on November 7, 2020. There was no documentation the client was informed of criteria for admission, treatment, completion, and discharge in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client criteria completions and discharge are added to the intake packet in the medical record for client inspection and signature upon admission. COO will verify all admission packets include these documents to be signed by the client, offered a copy, and retained in the client's medical record.
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709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of a client orientation to include familiarization to the project policies.Client # 1 was admitted on November 30, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the project policies in the client record. Client # 2 was admitted on November 2, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the project policies in the client record. Client # 3 was admitted on December 11, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the project policies in the client record. Client # 4 was admitted on February 5, 2021 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the project policies in the client record. Client # 5 was admitted on May 1, 2020 and was discharged on July 31, 2020. There was no documentation of a client orientation to include familiarization to the project policies in the client record. Client # 6 was admitted on September 15, 2020 and was discharged on November 1, 2020. There was no documentation of a client orientation to include familiarization to the project policies in the client record. Client # 7 was admitted on September 8, 2020 and was discharged on November 7, 2020. There was no documentation of a client orientation to include familiarization to the project policies in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program rules that the client signs include the program policies. This notification will be retitled as modified as Project Policies and will be edited to include pertinent policies. The COO will ensure all documents meet compliance within days. These will be reviewed upon admission, client signature will be obtained and a copy offered. This will be retained in the client's medical record. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of a client orientation to include familiarization to the hours of operation.Client # 1 was admitted on November 30, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the hours of operation in the client record. Client # 2 was admitted on November 2, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the hours of operation in the client record. Client # 3 was admitted on December 11, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the hours of operation in the client record. Client # 4 was admitted on February 5, 2021 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the hours of operation in the client record. Client # 5 was admitted on May 1, 2020 and was discharged on July 31, 2020. There was no documentation of a client orientation to include familiarization to the hours of operation in the client record. Client # 6 was admitted on September 15, 2020 and was discharged on November 1, 2020. There was no documentation of a client orientation to include familiarization to the hours of operation in the client record. Client # 7 was admitted on September 8, 2020 and was discharged on November 7, 2020. There was no documentation of a client orientation to include familiarization to the hours of operation in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hours of operations are the facility is staffed 24/7, 365 a year. This will be included in the new admission packet in orientation. The client's signature will be obtained, a copy offered to the client and retained in the client's medical record. The COO will desire all documents are in compliance within days.
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709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of a client orientation to include familiarization to the fee schedule.Client # 1 was admitted on November 30, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the fee schedule in the client record. Client # 2 was admitted on November 2, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the fee schedule in the client record. Client # 3 was admitted on December 11, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the fee schedule in the client record. Client # 4 was admitted on February 5, 2021 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the fee schedule in the client record. Client # 5 was admitted on May 1, 2020 and was discharged on July 31, 2020. There was no documentation of a client orientation to include familiarization to the fee schedule in the client record. Client # 6 was admitted on September 15, 2020 and was discharged on November 1, 2020. There was no documentation of a client orientation to include familiarization to the fee schedule in the client record. Client # 7 was admitted on September 8, 2020 and was discharged on November 7, 2020. There was no documentation of a client orientation to include familiarization to the fee schedule in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Foster Hill Wellness has contracted insurance rates. Medicaid and local Single county authorities may have a specific contracted rate less than these figures. These rates are now disclosed in the Financial Agreement Form that will be presented to the client at the time of admission and documented in the client record. All fees will be disclosed and the client will be asked to sign the form in acknowledgement that it was reviewed and they received a copy given a copy. Two separate forms are now in the new client medical records, 1 for commercial insurance and 1 for others, (SCA, MA, Private Pay). In addition a median average per diem cost for services will be calculated (subject ,of course, to changes based on contracted rates with various insurance carriers). This median average fee will be formulated into a fee schedule and it will be posted in the intake office and client lounges. The COO will be responsible to ensure compliance within 60 days.
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709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of a client orientation to include familiarization to the services provided.Client # 1 was admitted on November 30, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the services provided in the client record. Client # 2 was admitted on November 2, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the services provided in the client record. Client # 3 was admitted on December 11, 2020 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the services provided in the client record. Client # 4 was admitted on February 5, 2021 and was still active at the time of the inspection. There was no documentation of a client orientation to include familiarization to the services provided in the client record. Client # 5 was admitted on May 1, 2020 and was discharged on July 31, 2020. There was no documentation of a client orientation to include familiarization to the services provided in the client record. Client # 6 was admitted on September 15, 2020 and was discharged on November 1, 2020. There was no documentation of a client orientation to include familiarization to the services provided in the client record. Client # 7 was admitted on September 8, 2020 and was discharged on November 7, 2020. There was no documentation of a client orientation to include familiarization to the services provided in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A description of Services Provided will be outlined and disclosed in each new admission packet and reviewed the client. The client will sign to acknowledge and receive a copy of the description of the services. The services provided will include type of services, hours, schedule. The COO will be responsible to ensure that this documentation is developed and included in each client record within 60 days. |
709.53(a)(4) LICENSURE Referral contact
709.53. 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:
(4) Referral contact.
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Observations
Based on four of seven client records reviewed, the facility failed to provide documentation of a complete client record to include a referral contact in client records # 3, 4, 6, and 7.Client # 3 was admitted on December 11, 2020 and was still active at the time of the inspection. There was no documentation in the client record of a referral contact.Client # 4 was admitted on February 5, 2021 and was still active at the time of the inspection. There was no documentation in the client record of a referral contact.Client # 6 was admitted on September 15, 2020 and was discharged on November 1, 2020. There was no documentation in the client record of a referral contact.Client # 7 was admitted on September 8, 2020 and was discharged on November 7, 2020. There was no documentation in the client record of a referral contact.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Foster Hill Wellness, LLC receives referrals for new clients. In some cases the client is a self referral and contacts our facility by phone or web site on their own behalf. The clients referral information will be clearly noted by the admission representative and counselors will follow up and document contact within 30 days of each referral. A consent for the referral person(s) will be obtained upon client admission. The Chief Operating Officer will ensure oversight for all referral contacts being made timely. A referral contact for follow-up care will be documented in the aftercare portion of the record for each client prior to discharge. The contact information will include documentation of the name or title of a person at the agency the client is being referred to a upon discharge, and the name of a contact person at Foster Hill Wellness in the event the client has questions or needs to seek re-admission or is unable to connect with the community referral resource. Corrections will be made in all records within 60 days.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance to the facility policy and procedure manual. The policy and procedure manual indicates that followup information will occur within one week of discharge. Client # 5 was admitted on May 1, 2020 and was discharged on July 31, 2020. There was no documentation of follow-up information in the client record. Client # 6 was admitted on September 15, 2020 and was discharged on November 1, 2020. There was no documentation of follow-up information in the client record. Client # 7 was admitted on September 8, 2020 and was discharged on November 7, 2020. There was no documentation of follow-up information in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Foster Hill Wellness, LLC will follow up with clients after discharge in accordance with facility policy and procedure. Follow up will be documented at the intervals of 30 day, 6 months and 1 year. (The policy initial follow-up time frame of 1 week was changed in the Policy and Procedure Manual) The Chief Operating Officer will ensure oversight for all referral contacts being made timely and review discharged client charts on a monthly basis.
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