INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11, 2023 through January 12, 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 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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705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, conducted on January 12, 2023 at approximately 11:00 AM, the facility failed to maintain a portable fire extinguisher, with a minimum of an ABC rating, on each floor of the facility. There were no fire extinguishers located in any of the men's bedroom cabins that are located on the facility grounds. This finding was 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 will maintain a portable fire extinguisher with a minimum of an ABC rating, which is located on each floor. Furthermore, If there is more than 2,000 square feet of floor space on a floor, Foster Hill Wellness will maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
Fire extinguishers will be added to the men's cabins that fall within the Fire safety, 28 Pa. Code § 705.10, on February 7th, 2023. Inspections of the grounds will be conducted monthly by the COO to ensure the deficiency does not reoccur.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client record reviewed.Per the requirement in Licensing Alert 02-21 and the facility ' s policy, the emergency contact is to be notified no later than 12 hours after a client is discharged from the facility against medical advice. Client # 7 was admitted to the inpatient non-hospital activity on May 14, 2022 and was discharged against medical advice on May 24, 2022. There was no documentation that the emergency contact was not notified of the client's discharge.This finding was 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. Foster Hill Wellness's policy now states that the emergency contact is to be notified no later than 12 hours after a client is discharged from the facility against medical/clinical advice. Foster Hill will submit our new policy before February 10th.
There will be a training on or before February 10th, 2023 regarding clients who leave against medical advice. Staff will be trained on calling the client's emergency contact and documenting it properly Per the requirement in Licensing Alert 02-21. The clinical supervisor will also be contacted immediately regarding all discharges to ensure staff is contacting the emergency contact and properly documenting within the 12 hours. The COO will also be contacted regarding all discharges and will ensure that these plans are implemented and documented according to Licensing Alert 02-21.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, conducted on January 11, 2023 at approximately 9:00 AM, the facility failed to secure hard copy client-identifying information within locked storage containers.In room 33, which was unlocked, there was a client list, with client-identifying information on it, found crumbled up and unsecured in the trashcan.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Foster Hill Wellness LLC administration will be trained on HIPAA and confidentiality requirements. Training will be completed within 30 days for all staff on HIPAA and confidentiality.
All staff will be trained on HIPAA and confidentiality requirements and all papers will be locked and secured in a binder within locked storage containers and/or shredded immediately if not in current use to ensure this deficiency does not happen again. At the end of every day, all staff will ensure there is no client-identifying information left in their offices. The facility/offices will be monitored by the COO and supervisor of residential services daily.
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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 facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of twenty-one client records reviewed.Client # 10 was admitted to the partial hospitalization activity on November 25, 2022 and was discharged on December 27, 2022. There was evidence of a family counseling session on December 10, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure. This is a repeat citation from the March 16, 2022 annual licensing inspection and the August 20, 2021 provisional license follow-up inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Foster Hill Wellness shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record prior to the disclosure of information. The clinical supervisor will review releases to ensure that this deficiency does not occur again. All counselors will be trained within 30 days and record checks will begin at once.
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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 facility failed to document the specific information to be disclosed on consent to release information forms in two of twenty-one client records reviewed. Client # 2 was admitted to the inpatient non-hospital activity December 20, 2022 and was still active at the time of the inspection. The release of information form to a medical provider was signed and dated by the client on January 10, 2023, but the release form failed to include the specific information to be disclosed. Client # 3 was admitted to the inpatient non-hospital activity December 16, 2022 and was still active at the time of the inspection. The release of information form to a referral source was signed and dated by the client on January 10, 2023, but the release form failed to include the specific information to be disclosed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be re-trained on the specific information to be disclosed on consent to release information forms. The Clinical Supervisor will also audit charts weekly to ensure staff is documenting specific information to be disclosed on the consent to release information forms. The training will be completed within 30 days and record checks will begin at once.
The release for client # 2 was corrected on 1/13/2023. The release for client # 3 was corrected on 1/11/2023. The director of care management will review all releases prior to the client getting assigned a room and weekly thereafter. Furthermore, the clinical supervisor will also audit charts weekly regarding the specific information to be disclosed on consent to release information forms. Training regarding the specific information to be disclosed on the consent to release information form will be added to all staff's professional development plans. The COO will meet with the clinical supervisor, Director of care management, and HR monthly to ensure compliance on this issue and that training is completed at hire and yearly thereafter and to determine if training is needed more often to ensure this deficiency does not recur. The COO is responsible for the supervision of this action.
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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 client records, the facility failed to document the purpose of the disclosure on release of information forms in five of twenty-one client records reviewed.Client # 2 was admitted to the inpatient non-hospital activity December 20, 2022 and was still active at the time of the inspection. The release of information form to a medical provider was signed and dated by the client on January 10, 2023, but the form did not include the purpose of the disclosure. Client # 3 was admitted to the inpatient non-hospital activity December 16, 2022 and was still active at the time of the inspection. The release of information form to a referral source was signed and dated by the client on January 10, 2023, but the form did not include the purpose of the disclosure. Client # 6 was admitted to the inpatient non-hospital activity on October 24, 2022 and was discharged on November 24, 2022. The release of information form to a referral source was signed and dated by the client on November 15, 2022, but the form did not include the purpose of the disclosure. Client # 10 was admitted to the partial hospitalization activity on November 25, 2022 and was discharged on December 27, 2022. The release of information form to a referral source was signed and dated by the client on November 15, 2022, but the form did not include the purpose of the disclosure. Client # 15 was admitted to the outpatient activity on December 28, 2022 and was still active at the time of the inspection. The release of information form to a referral source was signed and dated by the client on November 15, 2022, but the form did not include the purpose of the disclosure. This is a repeat citation from the March 16, 2022 annual licensing inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will be re-trained on or before February 10th, 2023 regarding the requirements of documenting the purpose of the disclosure, on the release of information forms. The clinical supervisor will complete weekly checks regarding the purpose of disclosure on the release of information forms. The release for client # 2 was corrected on 1/13/2023. The release for client # 3 was corrected on 1/11/2023. The release for client # 6 was corrected on 1/12/2023. The release for client # 10 was corrected on 1/12/2023. The release for client # 15 was corrected on 1/13/2023.
The director of care management will review all releases prior to the client getting assigned a room and weekly thereafter. Furthermore, the clinical supervisor will also audit charts weekly regarding the purpose of the disclosure. Training regarding the purpose of the disclosure will be added to all staff's professional development plans. The COO will meet with the clinical supervisor, Director of care management, and HR monthly to ensure compliance on this issue and that training is completed at hire and yearly thereafter. Record checks will begin at once. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire on consent to release information forms in twenty-one of twenty-one client records reviewed. In every client record reviewed, the release of information form to the funding source and to the pharmacy failed to include the date, event, or condition upon which the consent will expire. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On January 18th, 2023 the Director of Care Management called our EMR system to add the date, event, or condition upon which the consent will expire to the release of information form to the funding source and to the pharmacy. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.Client # 16 was admitted to the outpatient activity on July 20, 2022 and was administratively discharged on August 5, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On January 12th, 2023 the Clinical Supervisor called our EMR system to add a section to the Aftercare Plan/Discharge Instruction Form indicating whether the client was informed of their right to appeal their administrative discharge. This correction was approved by the inspector at that time.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was submitted and approved by the Department for the March 16, 2022 annual licensing inspection and the August 20, 2021 provisional license follow up inspection. Failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was again found to be a deficiency in the January 11, 2023 through January 12, 2023 annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Foster Hill Wellness's staff will be re-trained on consent to release information as well as the disclosures made in the client records to ensure that consent to release information is documented prior to the release of any client-identifying information within 30 days. Furthermore, training will be completed at hire and annually thereafter and charts will be checked weekly by our clinical supervisor to ensure compliance.
The Director of Care Management 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 releases needed are signed and dated properly. The clinical supervisor will also review all releases during the weekly chart review and alert the staff to any missing data or signatures. HR will ensure compliance by adding confidentiality training to the professional development plan for all staff to be completed at hire and yearly thereafter. Also, the COO will meet with the clinical supervisor, Director of care management, and HR monthly to ensure compliance and that training is completed at hire and yearly thereafter and to discuss if training is needed more often. The COO is responsible for the supervision of this action.
Leadership meetings are held at the end of every month regarding general compliance and the status of our POC plans. Leadership will review/evaluate all corrective actions to ensure ongoing compliance. The COO is responsible for the supervision of this action.
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