INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 2023, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to annually develop a written individual training plan for one personnel record reviewed.
Employee #1 was hired as the project director and facility director on April 15, 2019 and is still current in that position. The individual training plan documented during the inspection was dated April 15, 2022, to April 15, 2023. There was not a documented individual training plan for this annual evaluation period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Foster Hill Wellness, Chief Operation Officer, reviewed the observations provided by the Department, and on 7/21/2023 the COO will meet with the Project Director to develop a training plan appropriate to the project director's skill level With the COO and the project director's input. This individual plan was completed on July 21st, 2023, to April 15, 2024, and this will have 12 hours completed yearly and will be developed annually thereafter with input from both the employee and the supervisor. This plan will be based on an employee's previous education, experience, current job functions, and job performance. The Director of Residential Services ensures this is done annually for all employees. An Excel sheet with all hire dates, 90-day evaluations, yearly evaluations, and yearly individual plan's due dates has been updated and checked bi-weekly. The Director of Residential Services will ensure compliance with the regulation.
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709.28 (a) 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:
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Observations
Based on a review of the facility policy and procedure manual, the project director failed to develop a written procedure that complies with confidentiality and the disclosure of client-oriented information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Foster Hill Wellness has adjusted our policy to align with DDAP's requirements. On or before 7/28/2023 the COO, will update our policy and procedure for § 709.28 Confidentiality that complies with 4 pa. Code 255.5 confidentiality and the disclosure of client-oriented information per the licensing alert 03-22. This policy and procedure will be updated to also include ACT 33 which states a client can consent to disclose as much as they want as long as it matches the purpose of disclosure. Further, all staff will be required to complete the updated confidentiality training on or before August 11th, 2023. |
709.28 (a) (2) 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:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of the facility policy and procedure manual, the project director failed to develop a written procedures for the identification of project staff having access to records, and the methods by which staff gain access.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On or before 7/28/2023, the COO will update our confidentiality policy to include what staff has access to our EHR, how the staff receives access to our EHR, the procedure on how the staff is compliant with the security of the EHR, and which specific staff have access and how much access is given. The COO and Director of Residential Services will train the staff on or before 7/28/2023. This will be added to our orientation process for all new hires going forward. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the facility policy and procedure manual, the project is not following their written policies and procedures on administration of medication. The procedures indicate that a physician will oversee the administration of appropriate medication, however a physician is not onsite at all times and nurses are administering medication to clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/18/2023 the COO and Director of Residential Services updated the Medication control policy. It was updated to state that the staff nurse on shift will oversee the administration of medication to clients. This policy has been added to our Policy and Procedure manual on 7/18/2023 and emailed to DDAP.
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709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop and implement policies and procedures that included the documentation of the unusual incident for the following unusual incidents:
-Related to Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On or before 7/28/2023 the COO will update our policy on unusual incident reporting. All current staff and any new hires are trained on unusual incident reporting. Our policy needed to be updated to reflect what and how we train our employees. The COO will ensure ongoing compliance in our monthly management meeting. Further, there was a training on 7/28/2023 with all employees on this updated policy which includes:
-Related to Death or serious injury due to trauma, suicide, medication error, or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Theft, burglary, break-in or similar incident at the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Fire or structural damage to the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop and implement policies and procedures that included the prompt review and identification of the causes directly or indirectly responsible for the following unusual incidents:
-Related to Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On or before 7/28/2023 the COO will update our policy on unusual incident reporting. All current staff and any new hires are trained on unusual incident reporting. Our policy needed to be updated to reflect what and how we train our employees. The COO will ensure ongoing compliance in our monthly management meeting. Further, there was a training on 7/28/2023 with all employees on this updated policy which includes:
-Related to Death or serious injury due to trauma, suicide, medication error, or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Theft, burglary, break-in or similar incident at the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Fire or structural damage to the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop and implement policies and procedures that included the implementation of a timely and appropriate corrective action plan, when indicated for the following unusual incidents:
-Related to Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On or before 7/28/2023 the COO will update our policy on unusual incident reporting. All current staff and any new hires are trained on unusual incident reporting. Our policy needed to be updated to reflect what and how we train our employees. The COO will ensure ongoing compliance in our monthly management meeting. Further, there was a training on 7/28/2023 with all employees on this updated policy which includes:
-Related to Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Theft, burglary, break-in or similar incident at the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Fire or structural damage to the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop and implement policies and procedures that included the ongoing monitoring of the corrective action plan for the following unusual incidents:
-Related to Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On or before 7/28/2023 the COO will update our policy on unusual incident reporting. All current staff and any new hires are trained on unusual incident reporting. Our policy needed to be updated to reflect what and how we train our employees. The COO will ensure ongoing compliance in our monthly management meeting. Further, there was a training on 7/28/2023 with all employees on this updated policy which includes:
-Related to Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Theft, burglary, break-in or similar incident at the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Fire or structural damage to the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop and implement policies and procedures that included a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws for the following unusual incidents:
-Related to Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On or before 7/28/2023 the COO will update our policy on unusual incident reporting. All current staff and any new hires are trained on unusual incident reporting. Our policy needed to be updated to reflect what and how we train our employees. The COO will ensure ongoing compliance in our monthly management meeting. Further, there was a training on 7/28/2023 with all employees on this updated policy which includes:
-Related to Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Theft, burglary, break-in or similar incident at the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
-Fire or structural damage to the facility.
(1) Documentation of the unusual incident.
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. |
709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on a review of administrative paperwork and discussion with facility staff, the facility failed to notify the Department within 90 days of the change in activity at the facility. The facility was utilizing buprenorphine as an other chemotherapy approach and had not made the Department aware.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 8th, 2023 the Director of Residential Services emailed a document stating that Foster Hill Wellness d/b/a Malibu Wellness Ranch would like to add Buprenorphine/other chemotherapy to our license. The facility has already received correspondence from DDAP with a letter and license stating it was approved on July 18th, 2023. Further, Foster Hill Wellness will notify the department within 90 days of any new change in the activity at the facility. The COO will ensure compliance with all and any changes regarding Foster Hill Wellness. If any changes are made the COO will ensure DDAP will be aware of the changes within 90 days. This will be discussed during our monthly management meetings to ensure ongoing compliance.
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