INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13, 2024 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the project failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 6 was admitted on April 2, 2024 and was discharged on April 28, 2024. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #6 was discharged prior to the inspection. To improve processes, we've hired a new nursing supervisor to oversee nursing staff and their documentation, including consents and releases. The supervisor will conduct weekly chart audits, and each shift will double-check the previous shift's admission paperwork for accuracy and completeness.
Additionally, the Clinical Supervisor will conduct weekly audits to ensure this is being completed promptly. Monthly training will be held regarding the consent to release forms specifically the funding source releases among others. The COO will meet each month with the nursing supervisor, Clinical Supervisor, Director of Care Management, and Human Resources to ensure compliance with these requirements. This includes verifying that training is completed upon hiring, as well as monthly and annually thereafter. Additionally, the team will assess whether more frequent training is necessary to prevent this issue from recurring. The COO will oversee this entire process. |
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 client records, the project failed to document the specific information to be disclosed on consent to release information forms in one of seven client records reviewed.
Client # 5 was admitted on June 24, 2024 and was discharged on June 27, 2024. A release of information form to another treatment provider was signed by the client on June 24, 2024, but the release form did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #5 was discharged before the inspection. To enhance our processes, we have hired a new nursing supervisor to oversee the nursing staff/nursing aids and their documentation, particularly regarding consent forms. The supervisor will conduct weekly chart audits, and each shift will review the previous shift's admission paperwork to ensure accuracy and completeness.
Additionally, the Clinical Supervisor will conduct weekly audits to ensure this is being completed promptly. Monthly training will be held regarding the consent to release forms specifically to another treatment provider to include the specific information to be disclosed. This month's training will be held on or before November 12th, 2024. The COO will meet each month with the nursing supervisor, Clinical Supervisor, Director of Care Management, and Human Resources to ensure compliance with these requirements. This includes verifying that training is completed upon hiring, as well as monthly and annually thereafter. Additionally, the team will assess whether more frequent training is necessary to prevent this issue from recurring. The COO will oversee this entire process. |
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 client records, the project failed to document the purpose of the disclosure on release of information forms in one of seven client records reviewed.
Client # 5 was admitted on June 24, 2024 and was discharged on June 27, 2024. A release of information form to another treatment provider was signed by the client on June 24, 2024, but the release form did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #5 was discharged before the inspection. To enhance our processes, we have hired a new nursing supervisor to oversee the nursing staff/nursing aids and their documentation, particularly regarding consent forms. The supervisor will conduct weekly chart audits, and each shift will review the previous shift's admission paperwork to ensure accuracy and completeness.
Additionally, the Clinical Supervisor will conduct weekly audits to ensure this is being completed promptly. Monthly training will be held regarding the consent to release forms specifically to another treatment provider to include the purpose of the disclosure. This month's training will be held on or before November 12th, 2024. The COO will meet each month with the nursing supervisor, Clinical Supervisor, Director of Care Management, and Human Resources to ensure compliance with these requirements. This includes verifying that training is completed upon hiring, as well as monthly and annually thereafter. Additionally, the team will assess whether more frequent training is necessary to prevent this issue from occurring again. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the project failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.
Client # 7 was admitted on January 28, 2024 and was administratively discharged on January 29, 2024. There was no documentation, in the record, indicating the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #7 was discharged before the inspection took place. The policy and procedures, along with the new form, were implemented in 2023. The employee responsible for this client's discharge is new to the facility and has received re-training on the policies and procedures related to administrative discharges. Additionally, a nursing supervisor has been hired to oversee all employees at our 3.7 level of care. Weekly chart audits will be conducted by the nursing supervisor to ensure proper documentation. Moving forward, before any administrative discharges occur, the nursing supervisor must be contacted to verify that all documentation is complete and accurate.
There will be a training session on or before December 12, 2024, regarding procedures for administrative discharges for all employees. The clinical supervisor will also conduct weekly audits of charts to ensure documentation is correct. The Chief Operating Officer (COO) will meet monthly with the clinical supervisor, the Director of Care Management, the Director of Residential Services, and the nursing supervisor to monitor compliance on this issue. They will ensure that training is completed at hire and annually thereafter, and will assess if additional training is needed to prevent any recurrence of deficiencies. The COO is responsible for overseeing this process.
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