INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wellspan Philhaven 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on review of The Staffing Requirements Facility Summary Report, the FTE counselor caseload for counselor # 4 in the outpatient program exceeded 35 active clients.
Employee # 4 was hired as a counselor on June 26, 2017 and was still in this position at the time of the inspection. Employee #4 was reported to have 20 hours per week devoted to their 20 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 20/40 = .5(FTE); 20/.5 = 40, which equals to a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will review caseloads for all SUD counselors and ensure part-time/ 0.5 Counselors' caseloads do not exceed 17 clients in their direct care. 20/40 = 0.5 (FTE); 17/ 0.5 = 34:1 Any counselors who have more than 17 SUD clients currently will not accept new referrals and will make clinically appropriate transition plans for existing clients to reduce staffing. Counselors will maintain current caseloads and indicate availability to acquire new clients. The Facility Director will monitor caseloads monthly. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of all staff being instructed on the use of the fire extinguisher upon employment.
Employee # 8 was hired as a counselor on February 8, 2022 and was still in this position at the time of the inspection. Documentation of fire extinguisher training did not occur upon hire but instead occurred on March 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director updated the new employee on-boarding checklist to reflect the need for this required training. All new employees will receive fire extinguisher training upon employment within 7 days. Training will be provided by the Facility Director or Designee.100% of new employee files will be audited monthly to ensure that fire extinguisher training was completed within 7 days of employment. Corrective actions will be implemented when non-compliance is observed. Monitoring results will be reported monthly to the Quality Management Committee by Manager, Accreditation and Licensure, or designee. Corrective actions will be determined effective after ≥90% compliance for three consecutive reporting periods. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of all staff being trained to perform assigned tasks during emergencies upon employment.
Employee # 8 was hired as a counselor on February 8, 2022 and was still in this position at the time of the inspection. Documentation of emergency training did not occur upon hire but instead occurred on March 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director updated the new employee on-boarding to reflect the need for this required training. All new employees will receive emergency training upon employment within 7 days. Training will be provided by the Facility Director, or designee.
100% of new employee files will be audited monthly by the Facility Director to ensure that emergency training was completed within 7 days of employment. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of the facility electronic medical record system, the facility failed to provide a data collection record keeping system to allow for the efficient retrieval of data needed to measure the project's performance. The electronic record did not provide the information needed for the audit to be performed by the auditor but instead, needed the assistance of staff to locate drug and alcohol records as the IT department did not provide the required access. Also, the electronic record does not clearly indicate drug and alcohol activities from other medical records stored in the system.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director of Project Operations for WellSpan Philhaven Ambulatory Services met with the Epic Electronic Health Record Build Team to create improved regulatory review access specific to SUD services. A Specialized EMEDIC Account will be offered in future inspections. The Facility Director will provide a list of clients to Health Information Management to compile the client records for review prior to the licensing visit. This will ensure the records are efficiently accessible for the Licensing Specialist to view. |
709.34 (a) (6) 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:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Policy addressing 709.34 Reporting of Unusual Incidents has been updated by Project Director or designee by 12/30/22 to include site specific reponses to "event at the facility requiring the presence of police, fire, or ambulance personnel"
100% of involved staff will be trained to policy by 2/14/23. Training will be provided by Project Director or designee. Any staff member on extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff responsible for reporting unusual incidents will be trained to the workflow during their new hire probationary period. |