INITIAL COMMENTS
|
This report is a result of an on-site provisional license follow-up inspection conducted on August 16-20, 2021, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #5,6,7 and 8 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee # 5 was hired as a direct support professional on April 15, 2019 and was due to have the required trainings no later than April 15, 2021.Employee # 6 was hired as a direct support professional on May 6, 2019 and was due to have the required trainings no later than May 6, 2021.Employee # 7 was hired as a direct support professional on May 29, 2019 and was due to have the required trainings no later than May 29, 2021.Employee # 8 was hired as a direct support professional on June 17, 2019 and was due to have the required trainings no later than June 17, 2021. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff development is critical in our effort to provide quality care for our clients. Employee numbers 5,6,7, and 8 did not have the minimum of 6 hours of HIV/ AIDS and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
The plan to correct this is to provide the proper training and make sure all required staff continue to meet all regulatory training requirements. To safeguard from employees falling short we have modified our policy in regard to Professional Development Plans. The clinical supervisor will be responsible for monitoring all staff training requirements and continue to insure that all required training are fulfilled and meet all regulatory timeframes.
Corrective Action: We have completed the required training for employees # 5, 6, 7, and 8 on August 26, 2021. The training was provided by John Stefani from Safety Training Services Inc. The training title was HIV/AIDS & Communicable Disease. Certificates were provided and they meet the regulatory requirements. Many other employees also participated in the training.
The clinical director is responsible for the supervision of this action
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #4's employee record.Employee # 4 was promoted to counselor on January 4, 2020 and was still in that position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020. Employee # 4 was short 9 training hours for the year.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #4 was required to complete 25 clock hours of training annually. Employee #4 was 9 hours short of this requirement.
We will provide the proper training and make sure all required staff continue to meet all regulatory training requirements. To safeguard from employees falling short we have modified our policy in regard to Professional Development Plans. The clinical supervisor will be responsible for monitoring all staff training requirements and continue to insure that all required training are fulfilled and meet all regulatory timeframes.
Corrective Action: Employee #4 will attend and complete the 9 hours of training required by the end of this calendar year 2021. In addition, the clinical supervisor and employee #4 will review employee #4s Professional Development plan and they will make sure that all regulatory trainings required (25 hours) are also completed by the end of this calendar year 2021. The clinical director is responsible for the supervision of this action
|
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
|
Observations
Based on a physical plant inspection that occurred on August 16, 2021, it was observed that the facility failed to maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum of 15 feet. There is a room in the basement being used as a gym by the clients. The gym does not have two exits available for clients to use.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
We will close the GYM immediately until a second form of egress is constructed. We will notify the PA department of drug and alcohol when this construction is completed. |
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.
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in seven out of twenty-one records.Client # 2 was admitted on March 27, 2021 and was discharged on June 25, 2021. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes.Client # 3 was admitted on May 28, 2021 and was discharged on June 16, 2021. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes.Client # 4 was admitted on May 25, 2021 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes.Client # 5 was admitted on June 21, 2021 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes.Client # 8 was admitted on May 9, 2021 and was discharged on June 22, 2021. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes.Client # 11 was admitted on August 2, 2021 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes.Client # 18 was admitted on June 2, 2021 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent to release to a funding source prior to the release of information for billing purposes.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Client #2, #3, #8, have been discharged and completing or securing this release is unlike. However, we will reach out to the discharged clients and see if they would be willing to sign and return the release so we can attach it to their medical record.
Clients #4, #5, #11, #18 are still active and we will secure the proper signatures on the consent forms in our (KIPU) EMR system. This action will be completed by our Admissions staff ASAP or by 9/30/2021.
We need to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. This release is consent to release to a funding source prior to the release of information for billing purposes.
Corrective Action: Our Admission staff will review all confidentiality releases prior to admission to insure that all releases required are signed and completed before they are assigned a room. During the initial phase of the treatment plan process the primary therapist will review the releases with the client and make sure all the possible release needed are signed and dated properly. The clinical supervisor will also review all release during the weekly chart review and alert the staff to any missing data or signatures. The clinical director is responsible for the supervision of this action
|
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on the review of client records, the facility failed to document a completed consent to release information in one out of twenty-one records reviewed, as there were forms that were missing required information.Client # 17 was admitted on May 6, 2021 and was discharged on June 10, 2021. There were two consent to release forms dated on June 9, 2021 that did not contain a dated signature of the client. The releases were for a pharmacy and a billing company that is used by the facility.These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
We need to have a signed and dated release for our billing company and the pharmacy for Client #17 We have two release forms in the file however they did not have a dated signature from Client #17. Our admissions staff will reach out to Client #17 and see if we could obtain a signed and dated release form to scan into the EMR system.
Corrective Action: Our Admission staff will review all confidentiality releases prior to admission to insure that all releases required are signed and completed before they are assigned a room. During the initial phase (72) hours of the treatment plan process the primary therapist will review the releases with the client and make sure all the possible release needed are signed and dated properly. The clinical director will also review all release during the weekly chart review and alert the staff to any missing data or signatures. The clinical director is responsible for the supervision of this action
action to be completed by 9/30/2021 |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record to include follow-up information in one out of three client records reviewed.Client # 10 was admitted on April 24, 2021 and was discharged on May 21, 2021. The client record did not contain documentation of follow-up information.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Completing client records including follow up documentation
Client # 10 was discharged on 5/21/2021 without follow up documentation in the client record. To remedy this we had the primary therapist reached out to client # 10 and completed a follow up interview with the client. The therapist documented all notes in the KIPU EMR system. The follow was done by the primary therapist and signed off by the clinical director.
We have modified our follow up policy to require all clients to be followed up upon discharge within 7 days of discharge, noted in the KIPU EMR system and signed off by the clinical director. The clinical director is responsible for the supervision of this action. This policy and action is completed as of 8/30/2021
|
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record to include follow-up information in two out of three applicable records reviewed.Client # 1 was admitted on January 15, 2021 and was discharged on April 16, 2021. The client record did not contain documentation of follow-up information.Client # 3 was admitted on May 28, 2021 and was discharged on June 16, 2021. The client record did not contain documentation of follow-up information.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Completing client records and providing follow up is critical to our clients success. Client #1 and Client #3 did not have the proper follow up documentation in their KIPU EMR record. The primary therapist under the supervision of the clinical director have reached out to both Client#1 and #3 to provide a follow up interview, Both Client #1 and #3 EMR have been updated, The clinical director is responsible for the supervision of this action
We have modified our follow up policy to require all clients to be followed up upon discharge within 7 days of discharge, noted in the KIPU EMR system and signed off by the clinical director. The clinical director is responsible for the supervision of this action. We will be in full compliance by 9/30/2021
|
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record to include follow-up information in two out of three applicable records reviewed.Client # 15 was admitted on February 1, 2021 and was discharged on April 9, 2021. The client record did not contain documentation of follow-up information.Client # 17 was admitted on May 6, 2021 and was discharged on June 10, 2021. The client record did not contain documentation of follow-up information.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client #15 and client #17 did not have proper follow up documentation in their KIPU EMR records. The primary therapist under the supervision of the clinical director have reached out to both Client#1 and #3 to provide a follow up interview, Both Client #1 and #3 EMR have been updated, The clinical director is responsible for the supervision of this action
We have modified our follow up policy to require all clients to be followed up upon discharge within 7 days of discharge, noted in the KIPU EMR system and signed off by the clinical director. The clinical director is responsible for the supervision of this action. We will be full compliance by 9/30/2021
|