INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12-14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, provided documentation and an interview with facility staff, the facility failed to document supervision of one of one counselor assistants in accordance with the regulations.Employee #5 was hired on 11/18/2019 as a counselor assistant with a qualifying Bachelor's Degree. However, the employee lacked experience and required close supervision. The only documented supervision note the facility was able to provide were notes of supervision on 11/25/2019, 1/13/2020/and 1/27/2020. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Deficiency 704.9(c) LICENSURE-Plan of Correction
Clinical Supervision is now being conducted with the employees that require it. Detailed documentation detailed by the Clinical Supervisor will given to the Director of Operations on a monthly basis by the 5th of the month.
Employee # 5 Counselor Assistant continues to be supervised closely by Clinical Supervisor as required per 704.9 Supervision notes are logged weekly for such sessions, then provided to the Director of Operations by the 5th of the month for prior moth for review to ensure timeliness frequency and content quality.
Supervision notes for Employee # 5 since inspection 2/14/2020, see below
2/17, 2/24,
3/4 , 3/9, 3/16, 3/23, 3/30
4/6, 4/15, 4/20, 4/27
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of documentation for staff certified in CPR and having First Aid training along with tech staff and clinical/admin staff schedules, the facility failed to ensure that at least one person trained in these skills was onsite during the project's hours of operation. A review of the staffing schedules from December 29, 2019 thru February 8, 2020 identified a lack of at least one person trained in First Aid and CPR certificaiton on the following dates and times:December 29, 2019 7am -9am and 6pm - 11pmDecember 30, 2019 6pm - 11pmJanuary 3, 2020 11pm -7am (January 4, 2020)January 4, 202 11pm - 7am (January 5, 2020January 5, 2020 7am - 9am and 6pm - 11pmJanuary 6, 2020 6pm - 11pm January 8, 2020 6pm - 11pm January 9, 2020 10 pm - 7am (January 10, 2020)January 10, 2020 6pm - 7am (January 11, 2020)January 11, 2020 3pm - 9am (January 12, 2020January 12, 2020 6pm - 11pmJanuary 13, 2020 6pm - 11pmJanuary 14,2020 10pm - 11pmJanuary 15, 2020 6pm - 11pmJanuary 16, 2020 10pm - 11pmJanuary 17, 2020 6pm - 7am (January 18, 2020)January 18, 2020 4pm - 9am (January 19, 2020) January 19, 2020 6pm - 11pmJanuary 20, 2020 6pm - 11pmJanuary 21, 2020 10pm - 11pmJanuary 22, 2020 6pm - 11pmJanuary 23, 2020 10pm - 11pmJanuary 24, 2020 6pm - 11pmJanuary 25, 2020 4pm - 11pmJanuary 26, 2020 7am - 9am and 6pm - 11pmJanuary 28, 2020 10pm - 11pmJanuary 29, 2020 6pm - 11pmJanuary 30, 2020 10pm - 11pmJanuary 31, 2020 6pm - 7am (February 1, 2020)February 1, 2020 4pm - 9am (February 2, 2020)February 2, 2020 6pm - 11pmFebruary 3, 2020 6pm - 11pmFebruary 4, 2020 10pm - 11pmFebruary 5, 2020 6pm - 11pmFebruary 6, 2020 10pm - 11pmFebruary 7, 2020 6pm - 7am (February 8, 2020)February 8, 2020 4pm - 7am (February 9, 2020) These findings were reviewed with facility staff during the licensing inspection.Upon learning of the gaps in coverage during the licensure inspection, the facility reworked the schedules to ensure coverage for the upcoming weeks.
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Plan of Correction
Deficiency 704.11. Staff development program. (c) General training requirements. (2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
A new schedule was completed by the Director of Operations on 2/14/2020, to ensure proper CPR compliance on all shifts and given to the auditor during the inspection. Additional CPR training conducted by a Safety Trainer for CPR/First Aid and was completed 2/27/2020 with 11 additional employees valid for 2 years. An attendance roster captured all attendees for training, CPR cards and certificate were filed in the employee file.This certification training adds to the 7 existing certified employees and allows for CPR certification compliance at all times for each shift. The Director of Operations will review new hires training needed and existing employee expiration on a quarter basis to schedule more training as needed.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of documents in client records the facility is having clients sign consents/forms that are not in compliance with 42 CFR part 2, 28 Pa. Code 709.28 and/or 4 Pa. Code 255.5(b) in nine of nine client records reviewed.Clint records PH1-PH6 and OP1 - OP3 contained the following consents Confidentiality Issues - The following documents are in all client records Document labeled Foster Hill Wellness, LLC Assignment of Benefits/Release of Medical Information - Exceeds 4 Pa. Code 255.5 as it includes the following statement: "In addition, I authorize Foster Hill Wellness, LLC to disclose any and all written information from the above named to my above named Insurance Company and/or its designated representatives, or other financially responsible party; at the determination of Foster Hill Wellness, LLC. Such disclosure shall be for reimbursement purposes for those services received. I hereby release Foster Hill Wellness, LLC and its officers, agents, employees, and any clinician associated with my case from all liability that may arise as a result of the disclosure of information to the above named Insurance Company(s) or their designated representatives."Document labeled - Foster Hill Wellness, LLC Consent for Treatment allows for the release of information without consent to the County Health Department, exceeding 4 Pa. Code 255.5(b) releasing to a government agency as there was no Qualified Service Organization Agreement with the Helath Department (per the Department's Policy Bulletin) provided at the time of the inspection. Additionally, the form contains the following statement without a right to revoke the consent: "I give my consent for the duration of my treatment and 90 days after discharge for Foster Hill Wellness, LLC to release information regarding my progress and location in treatment to Referring Agencies, Probation and Officers of the Court for the purpose of assuring my compliance with an order for treatment (if requested)." Document labeled - Foster Hill Wellness, LLC consent for Reporting Communicable Diseases allows for the release of information that exceeds 4 Pa. Code 255.5(b) release to a government agency, as there was no Qualified Service Organization Agreement with the Helath Department (per the Department's Policy Bulletin) provided at the time of the inspection.. Additionally, the consent does not meet the requirements of a valid consent to release information form as per 42 CFR and 28 Pa. Code 709.28. The consent lacks a dated witness signature. While the client signs with date noted, there is no witness line for a signature and date (there is a typewritten name of staff present and their credentials.The form Uses and Disclosures of Health Information does not comply does not comply with 42 CFR Part 2 and 4 Pa. Code 255.5(b) and 709.28. Document labeled Foster Hill Wellness, LLC Notice of Privacy Practices does not comply with 42 CFR Part 2 and 4 Pa. Code 255.5(b) and 709.28. Document labeled Foster Hill Wellness, LLC CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION Legal Entities/Employer/Funding Sources - Form 255" serves as a consent to obtain information as well as release. Adaptationally, the form allows for the release of information that exceeds 4 Pa. Code 255.Document labeled Foster Hill Wellness, LLC Confidentiality Policy states - The law stipulates that in the event of imminent danger to yourself or others, we must breach confidentiality. We must also act in accordance with any applicable State laws regarding mandatory disclosure of child, elder, or other abuse. Document labeled Foster Hill Wellness, LLC Consent For Release of Confidential Information does not allow for the verbal revocation of the consent. I understand that I May revoke this authorization at any time upon written notice to Foster Hill Wellness, LLC.
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Plan of Correction
Deficiency 3 709.28- The revised forms include specific language which is consistent with the requirements of 4 Pa. Code 255.5 and 42 CFR Part II. The corrections to the forms were made by Director of Operation and submitted to Foster Hill Wellness medical records company for updated forms to be used going forward. All revision will be completed by 5/31/2020.The Director of Operations will be responsible to ensure ongoing compliance with this standard.
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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
Based on a review of facility policies and procedures, the facility lacked documentation that they informed clients of their rights in nine of nine records reviewed.Client records PH1 - PH6 and OP1 - OP3 were reviewed 2/12/2020 - 2/14/2020 for doucmentation that the clients had been informed of their rights. There was no documentation in the records that the clients had been informed of their rights. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Deficiency for Observation# 0299 for 709.28 Confidentiality: Our plan of correction is that the revised forms include specific language which is consistent with the requirements of for Confidentiality and Client Rights requirements. The corrections to the forms were made by the Director of Operations and submitted to medical records company or updated forms to be used going forward. All revision will be completed by 5/31/2020. Director of Operations will be responsible to ensure ongoing compliance with this standard.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of nine client records February 12-14, 2020, PH1 - PH6 and OP1 - OP3, the facility failed to document medications in accordance with 709.32 and the facility's policy on documenting medication administration.At the time of the inspection the facility policy stated that medications were to be self-administered observed by the Director of Operations. Medications were being self-administered but were not always observed by the Director of Operations. Facility tech staff were observing self-administration when the Director of Operations was unavailable. This resulted in in incomplete and/or missing documentation relative to medications in seven of nine records reviewed.Client # PH1 was admitted on 1/20/2020 and still an active client at the time of the inspection. The facility failed to document that the client received medications as follows: Propranolol 20 mg 2/5/2020, Buspirone 15 mg and evening meds on 28/2020 Client # PH2 was admitted on 1/30/2020 and still an active client at the time of the inspection. The facility failed to document that the client received medications as follows: Propranolol 10 mg at the 3pm-6pm med time on 2/1/2020, 2/6/2020, 2/7/2020/and 2/9-13/2020, Lansoprazole one capsule daily 2/9-12/2020. Gabapentin 400 mg at the 12pm-3pm med time 2/1/2020, 2/4/2020, 2/6/2020, 2/7/2020 and 2/9-12/2020. 2/5/2020. Client # PH4 was admitted on 2/7/2020 and still an active client at the time of the inspection. The facility failed to document that the client received medications as follows: Clindamycin 400 mg at the 12pm -3pm med time on 2/1/2020, 2/4/2020, 2/6/2020, 2/7/2020 and 2/9-12/2020.: Client # PH6 was admitted on 1/31//2020 and still an active client at the time of the inspection. The facility failed to document that the client received medications as follows: Bupropion XL 300 mg 2/8/2020 and 2/9/2020, Citalopram 20mg 2/8/2020 and 2/9/2020, Melatonin 3 mg 2/5/2020 and 2/8/2020, Naltrexone 50 mg 2/8/2020Client # OP1 was admitted on 11/21//2019 and still an active client at the time of the inspection. The facility failed to document that the client received medications as follows: Naltrexone HCL 50 mg 2/10/2020 and 2/11/2020.Client # OP2 was admitted on 12/26/2019 and still an active client at the time of the inspection. The facility failed to document that the client received medications as follows: Clonidine .02 mg 2/1/2020. Hydroclorot 25 mg 2/1/2020, Venlafaxine ER 75 mg 2/1/2020, Venlafaxine 37.5 mg 2/1/2020.Client # OP3 was admitted on 11/6//2019 and still an active client at the time of the inspection. The facility failed to document that the client received medications as follows: BIKTARVY 50-200-25 2/1/2020 These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Deficiency § 709.32. Medication control. Plan of Correction
A new Wellness Assistant was hired 2/16/2020 and trained to maintain medication controls. Daily patient initials are reviewed, noted and changes are updated timely by the Wellness Assistant. The Director of Operations reviewed all medication paperwork, filling and error reports weekly. Monthly medication log assessment and any noted issues are completed by the Wellness Assistance and inspected by the Director of Operations on a monthly basis. These reports are logged, signed and filed. The Director of Operations will review trends and training needs for staff on a monthly basis. The COO will inspect quarterly for trends, train and general compliance. Our Policy and Procedural Manual has been updated to reflect our revised processes for additional measures. Chapter 709, Sub Chapter C, page 148. section 6 A and 7 A were added. These measures are intended for added oversight and medication controls to prevent deficient findings and greater safety in the future.
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709.1(a) LICENSURE Subchapter A.General Provisions.Scope
709.1. Scope
(a) This chapter establishes the procedures for the issuance of a license by activity to free-standing 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.
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Observations
Based upon physical plant inspections and interviews with facility staff, Foster Hill Wellness, LLC was providing Outpatient and Partial Hospitalization treatment services at an unlicensed location.28 Pa. Code defines a facility as follows:Facility-The physical location in which ongoing, structured and systematic drug and alcohol services are delivered. A facility may have more than one activity. Additionally, 28 Pa. Code defines the Outpatient activity, Partial Hospitalization activity and Residential facility as follows:Outpatient activity-The provision of counseling or psychotherapeutic services on a regular and predetermined schedule. The client resides outside the facility. Partial hospitalization activity-The provision of psychiatric, psychological, social and other therapies on a planned and regularly scheduled basis. Partial hospitalization is designed for those clients who would benefit from more intensive services than are offered in outpatient treatment projects, but who do not require 24-hour inpatient care. Residential facility-An inpatient, nonhospital facility or inpatient freestanding psychiatric hospital that provides sleeping accommodations and provides one or more of the following activities: residential treatment and rehabilitation services, transitional living services or short-term detoxification services, 24 hours a day.At the time of the inspection, facility staff stated that all clients comprising the current population for the Outpatient and Partial Hospitalization activities resided at 351 Foster Hill Rd, Milford, PA 18337, but were receiving their counseing services at 351 B Foster Hill Rd, Milford, PA 18337 a separate deeded piece or property with a separate address..It was explained at the time of the inspection that there was no license for Partial Hospitalization or Outpatient activities at 351 B Foster Hill Rd. - The physical location in which ongoing, structured and systematic drug and alcohol services were being delivered. Furthermore, it was explained that while the licences for 351 Foster Hill Rd, included the Outpatient and Partial Hospitalization activities on the license, individuals receiving treatment at that location while living at that address could not be considered as receiving Outpatient and/or Partial Hospitalization treatment. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our plan of correction for Inspection Deficiency A001, Pa 709.1. Scope .28 Code is to request that our license is to be corrected to reflect address 351 and 351 B on our license certificate. Both locations on our campus had an onsite inspection and approved for our initial license for Facility 527052 in April of 2019. This would alleviate any confusion on future inspections, where levels of care are being provided.
In response to our conversation on June 11th, we will be submitting a letter 6/12/2020 to request an address correction to reflect our license number 527052 that has been inspected, licensed and approved by the licensing division in April 2019.
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