INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2021 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to maintain hot water temperature to not exceed 120 degrees in the facility bathroom. The water temperature was 130 degrees.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Facility work order was completed immediately on 12/16/21 to lower the water temperature. Will request facilities water temperature check quarterly. Will put in a Facilities request by January 15, 2022 |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the 2020-2021 facility fire drill log, the facility failed to provide documentation of an unannounced fire drill for the months of April through December 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills are completed monthly by office staff. An exception occurred during the months of April - December 2020, as all office staff worked remotely due to COVID-19. Edgar Square leadership team will ensure there is documentation of a monthly fire drill and list the number of participants regardless of remote working status. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility 2020-2021 fire drill log, the facility failed to provide documentation of the number of persons in the facility at the time of the drill for the years 2020-2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills are completed monthly by office staff. An exception occurred during the months of April - December 2020, as all office staff worked remotely due to COVID-19. Edgar Square leadership team will ensure there is documentation of a monthly fire drill and list the number of participants regardless of remote working status. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the purpose of the disclosure.Client # 5 was admitted on July 15, 2021 and was discharged on October 21, 2021. An informed and voluntary consent from the client for the disclosure of information to an "Other facility" dated July 12, 2021 did not include the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Accurately completing consents to release health care information will be reviewed at an upcoming staff meetings on January 5 and 6, 2022 to ensure staff document the purpose of the disclosure on every form. The Senior Clinic Director will assign Release of Information LMS training to all staff who have not completed the training in the past 6 months. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on three of seven client records reviewed, the facility failed to provide documentation of a complete client record to include intake procedures disclosing to the client the criteria for admission, treatment, and discharge in client records # 3, 5, and 6.Client # 3 was admitted on September 21, 2021 and was still active at the time of the inspection. Client # 5 was admitted on July 15, 2021 and was discharged on October 21, 2021. Client # 6 was admitted on April 20, 2021 and was discharged on December 8, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior clinic Director, Office Manager and SUD Team Lead will develop an Orientation Overview of our SUD services including all the requirements within code 709.91(b)(2)(i). The aforementioned parties will develop a Standard Work Process for reviewing this information with all clients entering the program. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on three of seven client records reviewed, the facility failed to provide documentation of a complete client record to include intake procedures disclosing to the client the project policies in client records # 3, 5, and 6.Client # 3 was admitted on September 21, 2021 and was still active at the time of the inspection. Client # 5 was admitted on July 15, 2021 and was discharged on October 21, 2021. Client # 6 was admitted on April 20, 2021 and was discharged on December 8, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior clinic Director, Office Manager and SUD Team Lead will develop an Orientation Overview of our SUD services including all the requirements within code 709.91(b)(2)(i). The aforementioned parties will develop a Standard Work Process for reviewing this information with all clients entering the program. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on three of seven client records reviewed, the facility failed to provide documentation of a complete client record to include client orientation to the project which shall include, but is not limited to, hours of operation in client records # 3, 5, and 6.Client # 3 was admitted on September 21, 2021 and was still active at the time of the inspection. Client # 5 was admitted on July 15, 2021 and was discharged on October 21, 2021. Client # 6 was admitted on April 20, 2021 and was discharged on December 8, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior clinic Director, Office Manager and SUD Team Lead will develop an Orientation Overview of our SUD services including all the requirements within code 709.91(b)(2)(i). The aforementioned parties will develop a Standard Work Process for reviewing this information with all clients entering the program. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on three of seven client records reviewed, the facility failed to provide documentation of a complete client record to include client orientation to the project which shall include, but is not limited to, fee schedule in client records # 3, 5, and 6.Client # 3 was admitted on September 21, 2021 and was still active at the time of the inspection. Client # 5 was admitted on July 15, 2021 and was discharged on October 21, 2021. Client # 6 was admitted on April 20, 2021 and was discharged on December 8, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior clinic Director, Office Manager and SUD Team Lead will develop an Orientation Overview of our SUD services including all the requirements within code 709.91(b)(2)(i). The aforementioned parties will develop a Standard Work Process for reviewing this information with all clients entering the program. . |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on three of seven client records reviewed, the facility failed to provide documentation of a complete client record to include client orientation to the project which shall include, but is not limited to, services provided in client records # 3, 5, and 6.Client # 3 was admitted on September 21, 2021 and was still active at the time of the inspection. Client # 5 was admitted on July 15, 2021 and was discharged on October 21, 2021. Client # 6 was admitted on April 20, 2021 and was discharged on December 8, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior clinic Director, Office Manager and SUD Team Lead will develop an Orientation Overview of our SUD services including all the requirements within code 709.91(b)(2)(i). The aforementioned parties will develop a Standard Work Process for reviewing this information with all clients entering the program. Staff will be trained in the standard work and the Clinic director will monitor implementation of the process. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on three of seven client records reviewed, the facility failed to provide documentation of a complete client record to include a consent to treatment in client records # 2, 3, and 5.Client # 2 was admitted on October 11, 2021 and was still active at the time of the inspection.Client # 3 was admitted on September 21, 2021 and was still active at the time of the inspection. Client # 5 was admitted on July 15, 2021 and was discharged on October 21, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will review consent for treatment with the client and obtain verification of understanding from the client. A record of client receipt and understanding will be available in the medical record. The Clinical Quality team will randomly audit client records to assure this process is being followed. |
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.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur with a referral within one week by phone call and documented in the client record.Client # 7 was admitted on August 13, 2021 and discharged on September 9, 2021. There was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Clinic Director and SUD Team lead updated the program Follow-up policy consistent with feedback from our local County SCA. Standard work will be developed according to the policy update. A Standard Work Process for the policy update will be completed by the aforementioned parties. Clinical and support staff will receive training in the updated policy and Standard Work Process. The SUD Team Lead and Clinic Director will monitor patient records for follow-up according to the policy. |