INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15-16, 2022, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of six personnel records, the facility failed to document participation in any monthly meetings between the clinical supervisor and their supervisor to discuss their duties and performance for the first 6 months of employment in that position. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Clinical Director will participate in documented, monthly supervision meetings with the COO to discuss clinical responsibilities and job performance.
Corrective Action:
The Clinical Director will participate in documented, monthly supervision meetings with the COO to discuss clinical responsibilities and job performance for the next 6 months. The Clinical Director's skill level will be evaluated and documented prior to a decrease in frequency in supervision. If a new clinical director was hired the same procedure will be followed. The COO with be in charge of monitoring and conducting this supervision.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of six personnel records, the facility failed to ensure there was a mechanism to collect feedback on completed trainings. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Training Evaluation Form will be completed by each employee/attendee of every in-service and out-service training.
Corrective Action:
Training Evaluation Forms will be disseminated and collected by the Supervisor of Residential Services and Clinical Director to be placed in personnel files upon completion.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of six personnel records reviewed the facility failed to ensure that one staff had the mandatory training in communicable diseases within the required time frames.Staff #6 was hired as Behavioral Technician on 10/28/19. The staff person was required to have 4 hours of TB/STD training and 6 hours of HIV/AIDS training by October 28, 2021, but at the time of the inspection, the staff person had no documentation of training in these areas. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from licensing inspection dated August 20, 2021.
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Plan of Correction
Staff development is critical in our effort to provide quality care for our clients. Employee #6 did not have the minimum 6 hours of HIV/AIDS and 4 hours of TB/STD/Hepatitis training within the regulatory timeframe.
Corrective Action:
Training is scheduled for June 3, 2022 and will be provided by Safety Training Services Inc. The training title is HIV/AIDS & Communicable Diseases. Certificates will be provided and they will meet the regulatory requirements. This training will be attended by Employee #6.
A new policy was put into place all new employees will attend required trainings within one year of hire. Supervisor of Residential Services will schedule all necessary trainings.
The clinical director and COO are responsible for the supervision of this action.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The ABC fire extinguisher located in the kitchen was last inspected and approved in January of 2021. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Sussex County Fire Sales and Services came to the facility on 03/17/2022 to inspect and approve the fire extinguisher in question. A new inspection tag was placed.
Corrective Action:
A map and key has been created to locate all fire extinguishers on site and Facilities Director will be responsible for keeping up with all inspections and check tags. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the fire drill record from August 2021 through March 2022, the facility failed to conduct unannounced fire drills at least once a month. There was no documented fire drill for September 2021. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A training was completed by COO on 03/18/2022 with BHT Supervisor and Supervisor of Residential Services on proper fire drill protocols and how to properly document the fire drill log.
Corrective Action:
BHT Supervisor will conduct monthly fire drills and document the fire drill log. The fire drill log will be monitored by the Supervisor of Residential Services and COO. |
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 a review of twenty-one client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one client record reviewed. Client #5 was admitted on October 5, 2021 and was discharged on January 25, 2022. An informed and voluntary consent to a billing and collections agency signed and dated by the client on December 19, 2021, did not include the specific information disclosed. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Client #5 has been discharged and obtaining a corrected, signed release is unlikely. However, we will reach out to the discharged client and see if they are willing to sign and return an updated/correct release so we can attach it to their medical record.
Corrective Action:
Training will be conducted for employees responsible for creating consents and releases. This training will be facilitated by the clinical director. Admission Staff will review all consents and releases to ensure they are completed fully and accurately. During the initial phase of the treatment planning process, the primary counselor will make sure all the necessary releases are signed and completed properly. The clinical director will review all releases during weekly chart reviews and alert staff to any missing data or signatures.
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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 twenty-one client records, the project failed to obtain an informed and voluntary consent from the client that included the purpose of disclosure in one client record reviewed. Client #5 was admitted on October 5, 2021 and was discharged on January 25, 2022. An informed and voluntary consent signed and dated by the client on December 19, 2021, to a billing and collections agency did not include the purpose for disclosure of the information contained in the client record. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Client #5 has been discharged and obtaining a corrected, signed release is unlikely. However, we will reach out to the discharged client and see if they are willing to sign and return an updated/correct release so we can attach it to their medical record.
Corrective Action:
Training will be conducted for employees responsible for creating consents and releases. This training will be facilitated by the clinical director. Admission Staff will review all consents and releases to ensure they are completed fully and accurately. During the initial phase of the treatment planning process, the primary counselor will make sure all the necessary releases are signed and completed properly. The clinical director will review all releases during weekly chart reviews and alert staff to any missing data or signatures.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of twenty-one client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a copy of the client consent was offered to the client and a copy maintained in the record in four client records reviewed. Client #1 was admitted on January 19, 2022 and was current at the time of the inspection. A release signed and dated by the client on January 19, 2022, to a medical facility and a release signed and dated on February 22, 2022, to a dental facility did not indicate if a copy of the client consent was offered to the client.Client #2 was admitted on January 5, 2022 and was current at the time of the inspection. A release signed and dated by the client on January 5, 2022, to a medical facility did not indicate if a copy of the client consent was offered to the client. Client #5 was admitted on October 5, 2021 and was discharged on January 25, 2022. A release signed and dated by the client on December 19, 2021, to a billing and collections agency did not indicate if a copy of the client consent was offered to the client. Client #19 was admitted on November 25, 2021 and was discharged on February 20, 2022. Releases signed and dated by the client on November 25, 2021, for three medical providers, a behavioral health services provider, an insurance provider and a pharmacy did not indicate if a copy of the client consent was offered to the client. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Clients #5 and #19 have been discharged and obtaining a corrected, signed release is unlikely. However, we will reach out to the discharged client and see if they are willing to sign and return an updated/correct release so we can attach it to their medical record.
Corrective Action:
Clients #1 and #2 are still active and corrected releases have been signed and placed in the medical record. Training will be conducted for employees responsible for creating consents and releases. This training will be facilitated by the clinical director. Admission Staff will review all consents and releases to ensure they are completed fully and accurately. During the initial phase of the treatment planning process, the primary counselor will make sure all the necessary releases are signed and completed properly. The clinical director will review all releases during weekly chart reviews and alert staff to any missing data or signatures.
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