INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted March 16-19, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Foster Hill Wellness was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on client and staff interviews and chart reviews the facility failed to ensure that qualified staff were providing clinical services. Client chart documentation showed that clinical groups were facilitated by Behavioral Health Techs/Case Managers on the following dates: 3/18/21, 3/16/21, 3/11/21, 3/9/21, 3/6/21, 3/4/21, 3/2/21 (2 notes), 2/27/21 (2 notes), 2/25/21, 2/23/21, 2/18/21, 2/16/21, 2/11/21, 2/9/21. In addition, Behavioral Health Techs facilitated Small Process Clinical Groups on the following dates: 3/17/21 (2 notes), 3/10/21 (3 notes), 3/9/21, 3/8/21 (3 notes), 3/5/21, 3/4/21 (3 notes), 3/3/21, 3/2/21, 3/1/21 (2 notes), 2/24/21 (2 notes) 2/17/21, 2/15/21, 2/10/21 (2 notes), 2/9/21, 2/8/21.
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Plan of Correction
Foster Hill is developing a new clinical schedule utilizing counselors leading all clinical therapeutic groups and small process groups, with documentation in the chart supporting as such. Behavioral Health Technicians will be conducting educational information presentations as well as recreational activity groups only. Clinical Director (starting employment on 4/19/21) to oversee and implement this new schedule as well as all required documentation in client charts. Compliance with this standard will be met by May 15, 2021. |
704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on client and staff interviews and a review of facility staffing schedules the facility failed to provide enough support service staff (Behavioral Health Techs) to insure the efficiency and safety of operations. It was reported that clients were not adequately supervised due to the number of techs working each shift.
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Plan of Correction
Foster Hill has hired a Site Supervisor and 3 new residential technicians as of Monday, April 12, 2021. Hiring is still ongoing in our continuing effort to bolster staff presence across all shifts. Clinical Director (starting employment on 4/19/21) will continue interviewing and hiring efforts that have been conducted to date by Chief Operation Officer. Full staffing compliment to be achieved by May 15, 2021. |
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 a review of employee records on March 16-19, 2021, the facility failed to assure that all counselors meet the requirements for this position.During the facility's annual licensing inspection February 16, 2021, 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.At the time of the complaint investigation on March 16, 2021, the facility had not yet demoted the counselor to a counselor assistant. These findings were reviewed with facility staff during the investigation.
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Plan of Correction
Foster Hill performed an internal investigation conducted by Chief Operation Officer, based on this reported deficiency. Upon review of employee's resume, education, supervision, and time employed with facility as an employee, we have concluded the following:
Employee #4 was hired on November 18, 2019 as a counselor assistant. Based on performance, employee was promoted to full primary counselor on January 4, 2020. While the counselor's merit is not in question, we recognize and appreciate the Department bring this lack of qualification issue to our attention. However, at this time, as of November 20, 2020, employee #4 now meets all qualifications as indicted by regulations to hold the position of full primary counselor. This employee's personnel file, resume, and other supporting documents have been updated to reflect the required one (1) year of clinical experience that this employee now possesses. As such, employee #4 is eligible to stay in his present role without further action needed. Compliance with the standard is effective immediately.
Further, Foster Hill is in process of hiring a full time Director of Compliance and Human Resources. This individual will have the responsibility of finalizing a review of the education, experience, credentials and qualifications of any new employee whose position has minimum requirements that must be met, as well as any current employee who is being considered for promotion, prior to hire or promotion event. This position is set to be filled by June 1, 2021 or earlier. Until such time as this new position is filled, these additional employee qualification checks will be overseen by the Chief Operation Officer to ensure this issue does not reoccur. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety. The exterior fire escape metal staircase on the women's residential unit was observed to have missing and/or worn slip-resistant coverings.
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Plan of Correction
Foster Hill installed brand new slip resistant covers on all steps on the metal staircase fire escape on 3/23/21 as confirmed visually by the Chief Operation Officer. Compliance with standard is effective immediately.
Further, Facility Maintenance Supervisor, will perform monthly safety inspections that will be inclusive of checking this area for any wear/tear issues and promptly replace or repair to ensure this issue does not reoccur. Monthly safety inspections will be confirmed by review of the Chief Operation Officer on an ongoing basis. |
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 the facility failed to maintain the exterior of the building and the building grounds to be free of hazards. Several fences were observed to be broken and one had a rusty nail protruding from it.
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Plan of Correction
Foster Hill is aware of fences damaged during snow removal operations during winter months of 2020-2021. All fences have been repaired or replaced as needed and all nails have been secured safely. Work performed by Facility Maintenance Supervisor and visually confirmed by Chief Operation Officer. Compliance with standard is effective immediately.
Further, Facility Maintenance Supervisor, will perform monthly safety inspections that will be inclusive of checking all fencing is in proper working order, good repair, and free from hazards to ensure this issue does not reoccur. Monthly safety inspections will be confirmed by review of the Chief Operation Officer on an ongoing basis.
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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
Based on a physical plant inspection during a complaint investigation, the facility failed to ensure privacy so that the counseling sessions were not seen outside of the counseling rooms. A camera was observed in the clinical treatment area located by the tech office/medication room.
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Plan of Correction
Foster Hill reviewed and confirmed that the surveillance camera observed by inspector in that area has no audio capabilities. Additionally that camera is pointed toward the doorway only and the group space is not located in the camera's field of view. This review and confirmation was performed by Chief Operation Officer. Compliance with this standard effective immediately. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store food items off the floor. Food was observed on the floor of the walk-in freezer. This was discussed with facility staff during the inspection/investigation.
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Plan of Correction
Foster Hill staff have been addressed directly by Chief Operation Officer and redirected to follow guidelines for keeping all food items off the floors. Newly hired Site Supervisor will hold duties which include monitoring of this area to insure food items are not stored on the floor. Compliance with this standard is effective immediately. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a review of tech logs and interviews with clients and staff, the facility failed to ensure that the residential sleeping areas were free from insect infestation. It was proven that the facility had bed bugs in at least one of the cabins that house male residents. The Behavioral Health Tech log dated 3/6/2021 indicated bed bugs in cabin 46. It was reported during client interviews that two cabins, including cabin 46, were tented for bed bug treatment a week and half before this investigation.
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Plan of Correction
Foster HIll was unaware of any bed bug presence until clients reported such concern to staff. Foster Hill, under the direction of Chief Operation Officer immediately responded by sanitizing patients and clothing, moving them to sterile rooms, heat sterilizing the cabins to over 120 Degrees, and investigating following these actions to insure erradication of all bed bugs. Further, additional protocols for screening and sanitizing belongings entering treatment have been implemented by Chief Operation Officer. Compliance with this standard is effective immediately. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection, the facility failed to limit client smoking to the designated smoking areas. Clients were observed smoking throughout the campus in nonsmoking areas.
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Plan of Correction
Foster Hill has hired additional behavioral health techs to provide more supervision and enforcement of the clients smoking only in designated areas. Clearly visible signage has been added to assist clients with knowing where smoking is permitted. This action has been confirmed by the Chief Operation Officer and compliance with this standard is effective immediately. |
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 policies and client chart documentation the facility failed to ensure that federal confidentiality laws were documented correctly. The facility's Confidentiality Policy includes a statement about reporting elder and other abuse, which does not comply with 42 CFR.
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Plan of Correction
Foster Hill confidentiality policy has been updated to be compliant with 42 CFR; all non-compliant language has been removed from all policy and procedure documentation as well as the Electronic Medical Record, effective immediately. Action confirmed by Chief Operation Officer and compliance with this standard is effective immediately.
Further, Foster Hill is in process of hiring a full time Director of Compliance and Human Resources. This individual will have the responsibility of reviewing all present, and new additions to, Foster Hill policies and procedures to ensure compliance with application State and Federal laws and codes. This position is set to be filled by June 1, 2021 or earlier. Until such time as this new position is filled, these policy and procedure reviews will be overseen by the Chief Operation Officer to ensure this issue does not reoccur. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client chart documentation the facility failed to comply with federal and state confidentiality laws. The facility's Consent to Treatment form included a statement about releasing information which is protected by federal and state confidentiality laws (42 CFR and Pa 255.5). This action requires a Consent to Release Information form.
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Plan of Correction
Foster Hill has removed this statement regarding the release of information from the Consent to Treatment document, effective immediately. This has been confirmed by the Chief Operation Officer and compliance with this standard is effective immediately. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on review of the facility's Unusual Incident Policy, the facility failed to comply with their procedures when responding to physical assault by clients as outlined in their policy. Documentation of physical altercations was observed for 11/12/2020 and 3/1/2021 in which the facility did not send DDAP usual incident reports.
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Plan of Correction
Foster Hill has implemented a new policy and provided staff training regarding the handling, documentation, reporting, and submissions of all unusual incidents to DDAP. This training was conducted by the Chief Operation Officer. Compliance with this standard is effective immediately.
Further, Foster Hill is in process of hiring a full time Director of Compliance and Human Resources. This individual will have the responsibility of scheduling regular trainings and in-services for all employees, to be inclusive of Unusual Incident Reporting guidance, documentation, and communication of events. This Director will also be responsible for receiving all facility incident reports and communicating any Unusual Incidents to the Department. This position is set to be filled by June 1, 2021 or earlier. Until such time as this new position is filled, the performance and verification of these trainings, as well as communication of any Unusual Incidents to the Department will be handled and overseen by the Chief Operation Officer to ensure this issue does not reoccur. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the tech logs, client records, client and staff interviews, the facility failed to report unusual incidents to the Department within three business days. Documentation was observed for the following incidents in which the facility did not report the incidents to the Department: a fight between clients dated 11/12/2020, physical altercations dated 3/1/2021 and bed bug infestation dated 3/6/2021.
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Plan of Correction
Foster Hill has implemented a new policy and provided staff training regarding the handling, documentation, reporting, and submissions of all unusual incidents to DDAP. This training was conducted by the Chief Operation Officer. Compliance with this standard is effective immediately.
Further, Foster Hill is in process of hiring a full time Director of Compliance and Human Resources. This individual will have the responsibility of scheduling regular trainings and in-services for all employees, to be inclusive of Unusual Incident Reporting guidance, documentation, and communication of events. This Director will also be responsible for receiving all facility incident reports and communicating any Unusual Incidents to the Department. This position is set to be filled by June 1, 2021 or earlier. Until such time as this new position is filled, the performance and verification of these trainings, as well as communication of any Unusual Incidents to the Department will be handled and overseen by the Chief Operation Officer to ensure this issue does not reoccur. |
709.81(a)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on client chart review the facility failed to assure appropriate treatment services based on client's admission criteria. Residential and nonresidential client services were combined. Clients were attending group sessions for outpatient, partial hospitalization and inpatient nonhospital residential and rehabilitation activities together.
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Plan of Correction
Foster Hill will follow the 2.5 Level of Care ASAM criteria for admission into our Partial Hospitalization Program. Foster Hill is the process of updating our Policies and Procedures regarding "Admission Criteria" to be aligned with ASAM criteria for this level of care. This update will be performed by May 15, 2021 and will be overseen to completion by Chief Operation Officer.
Foster Hill is in the process of conducting an internal review to insure that treatment services provided meet requirements for this level of care based on Admission Criteria. Clinical Director (to be hired on 4/19/21) will be responsible for this review and increasing necessary documentation in client charts. Compliance with this standard will be achieved by May 15, 2021.
Further, Foster Hill is in the process of hiring a full time Director of Compliance and Human Resources. This individual will be responsible for performance of ongoing reviews of all policies and procedures to ensure that they are in compliance with all applicable State codes as well as in alignment with ASAM criteria for level of care requirements. Additionally, this individual will meet quarterly with the Clinical Director and Chief Operation Officer to review all treatment processes and activities to further ensure ongoing compliance with standards. This new position of Director of Compliance and Human Resources is set to be filled by June 1, 2021. Until that time, these reviews will be performed jointly and on an ongoing basis by the Clinical Director and Chief Operation Officer. |
709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on client chart review the facility failed to assure appropriate treatment services based on client's admission criteria. Residential and nonresidential clients ' services were combined. Clients were attending group sessions for outpatient, partial hospitalization and inpatient nonhospital residential and rehabilitation activities together.
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Plan of Correction
Foster Hill will follow the 3.5 Level of Care ASAM criteria for admission into our Inpatient Nonhospital Residential and Rehabilitation program. Foster Hill is the process of updating our Policies and Procedures regarding "Admission Criteria" to be aligned with ASAM criteria for this level of care. This update will be performed by May 15, 2021 and will be overseen to completion by Chief Operation Officer.
Foster Hill is implementing additional clinical groups to insure that treatment services provided meet requirements for this level of care. Clinical Director (to be hired on 4/19/21) will be responsible for the increase in clinical programming and accompanying documentation in client charts. Compliance with this standard will by achieved by May 15, 2021.
Further, Foster Hill is in the process of hiring a full time Director of Compliance and Human Resources. This individual will be responsible for performance of ongoing reviews of all policies and procedures to ensure that they are in compliance with all applicable State codes as well as in alignment with ASAM criteria for level of care requirements. Additionally, this individual will meet quarterly with the Clinical Director and Chief Operation Officer to review all treatment processes and activities to further ensure ongoing compliance with standards. This new position of Director of Compliance and Human Resources is set to be filled by June 1, 2021. Until that time, these reviews will be performed jointly and on an ongoing basis by the Clinical Director and Chief Operation Officer. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 a review of client charts on March 16-19, 2021, the facility failed to assure that counseling services were provided according to individual treatment plans in four charts reviewed.Client #1 was admitted on 2/16/2021 and is still receiving treatment services. The individual treatment plan required 9 hours of clinical group weekly.Client #2 was admitted on 2/22/2021 and is still receiving treatment services. The individual treatment plan required 6 hours of clinical group weekly.Client #3 was admitted on 2/4/2021 and is still receiving treatment services. The individual treatment plan required 9 hours of clinical group weekly.Client #4 was admitted on 3/1/2021 and is still receiving treatment services. The individual treatment plan required 8 hours of clinical group weekly.
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Plan of Correction
Foster Hill, in the person of Chief Operation Officer, reviewed the charts of all four patients in question. While Foster Hill was able to confirm that the clients all received appropriate care, the documentation did not accurately reflect all services provided. Additionally, Foster Hill has hired a new clinical director starting 4/19/21 whose responsibilities will include immediate inservice training of clinicians regarding proper documentation and that treatment plans are being followed and prescribed care delivered. Monitoring of this issue will be performed through staff meetings, continued inservice trainings, and internal chart audits/tracers by the Clinical Director. Compliance with this standard will be effective by May 15, 2021. |
709.53(a)(1) LICENSURE Consent Forms
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:
(1) Consent forms.
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Observations
Based on a review of client charts on March 16-19, 2021, the facility failed to obtain the required consent to utilize client photographs and images for promotional purposes in all seven charts reviewed. Seven client charts were reviewed and were missing proper client consent. According to the chart documentation, each client chart contained the client's photograph for identification purposes. Also, the charts each contained a liability release form/consent for the promotion of the facility's Horseback Riding, ATVing, and Snowmobiling activities. However, client pictures were observed on the facility website promoting other activities for which there were no release forms.Client #1 was admitted on 2/16/2021 and is still receiving treatment services.Client #2 was admitted on 2/22/2021 and is still receiving treatment services. Client #3 was admitted on 2/4/2021 and is still receiving treatment services.Client #4 was admitted on 3/1/2021 and is still receiving treatment services.Client #5 was admitted on 1/25/21 and is still receiving treatment services.Client #6 was admitted on 2/17/2021 and is still receiving treatment services.Client #7 was admitted on 2/6/2021 and is still receiving treatment services.
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Plan of Correction
Foster Hill, in person of Chief Operation Officer, reviewed the observations provided by the Department. Upon review of all seven charts, Facility confirmed the presence of a release signed by each individual client upon admission granting consent for use of their photograph for identification purposes in the electronic medical record. All seven patients also signed a release upon admission for the use of video surveillance equipment for the purposes of safety and security during treatment. These consents are located in the "Admission" tab of the Electronic Medical Record system in each chart.
Chief Operation Officer is in process of revising the liability release and consent form to be inclusive of all recreational activities. Compliance with this standard will be effective on May 15, 2021
Further, Foster Hill is in process of hiring a full time Director of Compliance and Human Resources. This individual will have the responsibility of reviewing all present, and new additions to, Foster Hill policies and procedures, as well as consents/releases, to ensure compliance with application State and Federal laws and codes. This position is set to be filled by June 1, 2021 or earlier. Until such time as this new position is filled, these release and consent reviews and revisions will be overseen by the Chief Operation Officer to ensure this issue does not reoccur. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Based on client chart review the facility failed to assure appropriate treatment services based on client's admission criteria. Residential and nonresidential clients services were combined. Clients were attending group sessions for outpatient, partial hospitalization and inpatient nonhospital residential and rehabilitation activities together.
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Plan of Correction
Foster Hill will follow the 2.1 Level of Care ASAM criteria for admission into our Intensive Outpatient Program. Foster Hill is the process of updating our Policies and Procedures regarding "Admission Criteria" to be aligned with ASAM criteria for this level of care. This update will be performed by May 15, 2021 and will be overseen to completion by Chief Operation Officer.
Foster Hill is in the process of conducting an internal review to insure that treatment services provided meet requirements for this level of care based on Admission Criteria. Clinical Director (to be hired on 4/19/21) will be responsible for this review and increasing necessary documentation in client charts. This process will be completed and implemented by May 15, 2021.
Further, Foster Hill is in the process of hiring a full time Director of Compliance and Human Resources. This individual will be responsible for performance of ongoing reviews of all policies and procedures to ensure that they are in compliance with all applicable State codes as well as in alignment with ASAM criteria for level of care requirements. Additionally, this individual will meet quarterly with the Clinical Director and Chief Operation Officer to review all treatment processes and activities to further ensure ongoing compliance with standards. This new position of Director of Compliance and Human Resources is set to be filled by June 1, 2021. Until that time, these reviews will be performed jointly and on an ongoing basis by the Clinical Director and Chief Operation Officer. |
709.14(b)(2) 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:
(2) Change in name of the facility.
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Observations
Based on a review of administrative documentation, client charts, and an interview with the facility COO, the facility failed to advise the Department of its legal name change within 90 days. This finding was discussed with facility staff during the investigation.
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Plan of Correction
Foster Hill Chief Operation Officer will submit the d/b/a name change in conjunction with this plan of correction. Moving forward, all changes of this nature will be communicated to the Department within 90 days. Compliance with this standard is effective immediately.
Further, Foster Hill is in process of hiring a full time Director of Compliance and Human Resources. This individual will have the responsibility of auditing and reviewing reportable business activities, such as a legal name change, with the Chief Operation Officer on a quarterly basis and ensuring and that any and all necessary changes or events are communicated to the department in a timely fashion on an ongoing basis.
This position is set to be filled by June 1, 2021 or earlier. Until that time, this reporting process to the Department will be overseen by the Chief Operation Officer to ensure this issue does not reoccur. |