INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 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 Medical Group 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility fire drill log for the months of August 2021 and January 2022, the facility to provide documentation of a fire drill being conducted at different times of the day the months of September, October, November, December 2021, and January 2022. All fire drills were being conducted at 8 am.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Monthly fire drills will be conducted on different days of the week, at different times of the day and on different staffing shifts. Office Manager will update Standard Work for Fire Drills. Review Fire Drill report with Project Director prior to the end of each month to ensure 100% compliance.100% of involved staff will be educated to the Standard work for Fire Drills. Any staff on an extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved with the Standard Work for Fire Drills will be trained to the revised standard workflow during their new hire probationary period. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide documentation of the project director preparing, annually updating, and signing a written manual delineating project policies and procedures. The last documented update occurred on November 11, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director/Facility Director will review and revise policies annually, every July, and attest to this using a form to a shared file with updated policies, unless a revision is needed prior to that time. Upon review of policy, any changes to polices will be communicated to the team via email communication and reviewed during all staff meetings. 100% of all staff involved in the policy revision or annual policy review process will be educated and trained to the process. Any staff on extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved with the annual policy review process will be trained to the process during their new hire probationary period. |
709.34 (a) (1) 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:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide policies procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Revise unusual incident reporting policy to include documentation of physical assault or sexual assault by staff or a client, prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementation of a timely and appropriate corrective action plan, and reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policy will be revised by 6.1.22. The Project Director or designate will file a written and unusual incident report within 3 business days following the unusual incident. During the 90-day orientation period, new staff will be required to complete a web-based module on WellSpan's online reporting system. During the 90-day orientation period, new managers will need to complete web-based module on WellSpan's online reporting system, prior to being granted manager access in the reporting system. Reference guides are available to staff and managers, these guides review steps in entering a safety event and managing safety events. 100% of all staff involved or responsible for the reporting of unusual incidents will be educated and trained to the process. Any staff on an extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved in the unusual incident process will be trained to the workflow during their new hire probationary period.
Person responsible for corrective action is the project director. |
709.34 (a) (2) 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:
(2) Selling or use of illicit drugs on the premises.
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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 selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Revise unusual incident reporting policy to include documentation of physical assault or sexual assault by staff or a client, prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementation of a timely and appropriate corrective action plan, and reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policy will be revised by 6.1.22. The Project Director or designate will file a written and unusual incident report within 3 business days following the unusual incident. During the 90-day orientation period, new staff will be required to complete a web-based module on WellSpan's online reporting system. During the 90-day orientation period, new managers will need to complete web-based module on WellSpan's online reporting system, prior to being granted manager access in the reporting system. Reference guides are available to staff and managers, these guides review steps in entering a safety event and managing safety events. 100% of all staff involved or responsible for the reporting of unusual incidents will be educated and trained to the process. Any staff on an extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved in the unusual incident process will be trained to the workflow during their new hire probationary period.
Person responsible for corrective action is the project director. |
709.34 (a) (3) 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:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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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 death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Revise unusual incident reporting policy to include documentation of physical assault or sexual assault by staff or a client, prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementation of a timely and appropriate corrective action plan, and reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policy will be revised by 6.1.22. The Project Director or designate will file a written and unusual incident report within 3 business days following the unusual incident. During the 90-day orientation period, new staff will be required to complete a web-based module on WellSpan's online reporting system. During the 90-day orientation period, new managers will need to complete web-based module on WellSpan's online reporting system, prior to being granted manager access in the reporting system. Reference guides are available to staff and managers, these guides review steps in entering a safety event and managing safety events. 100% of all staff involved or responsible for the reporting of unusual incidents will be educated and trained to the process. Any staff on an extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved in the unusual incident process will be trained to the workflow during their new hire probationary period.
Person responsible for corrective action is the project director. |
709.34 (a) (4) 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:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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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 significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Revise unusual incident reporting policy to include documentation of physical assault or sexual assault by staff or a client, prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementation of a timely and appropriate corrective action plan, and reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policy will be revised by 6.1.22. The Project Director or designate will file a written and unusual incident report within 3 business days following the unusual incident. During the 90-day orientation period, new staff will be required to complete a web-based module on WellSpan's online reporting system. During the 90-day orientation period, new managers will need to complete web-based module on WellSpan's online reporting system, prior to being granted manager access in the reporting system. Reference guides are available to staff and managers, these guides review steps in entering a safety event and managing safety events. 100% of all staff involved or responsible for the reporting of unusual incidents will be educated and trained to the process. Any staff on an extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved in the unusual incident process will be trained to the workflow during their new hire probationary period.
Person responsible for corrective action is the project director. |
709.34 (a) (5) 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:
(5) Theft, burglary, break-in or similar incident at the facility.
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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 theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Revise unusual incident reporting policy to include documentation of physical assault or sexual assault by staff or a client, prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementation of a timely and appropriate corrective action plan, and reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policy will be revised by 6.1.22. The Project Director or designate will file a written and unusual incident report within 3 business days following the unusual incident. During the 90-day orientation period, new staff will be required to complete a web-based module on WellSpan's online reporting system. During the 90-day orientation period, new managers will need to complete web-based module on WellSpan's online reporting system, prior to being granted manager access in the reporting system. Reference guides are available to staff and managers, these guides review steps in entering a safety event and managing safety events. 100% of all staff involved or responsible for the reporting of unusual incidents will be educated and trained to the process. Any staff on an extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved in the unusual incident process will be trained to the workflow during their new hire probationary period.
Person responsible for corrective action is the project director. |
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
Revise unusual incident reporting policy to include documentation of physical assault or sexual assault by staff or a client, prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementation of a timely and appropriate corrective action plan, and reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policy will be revised by 6.1.22. The Project Director or designate will file a written and unusual incident report within 3 business days following the unusual incident. During the 90-day orientation period, new staff will be required to complete a web-based module on WellSpan's online reporting system. During the 90-day orientation period, new managers will need to complete web-based module on WellSpan's online reporting system, prior to being granted manager access in the reporting system. Reference guides are available to staff and managers, these guides review steps in entering a safety event and managing safety events. 100% of all staff involved or responsible for the reporting of unusual incidents will be educated and trained to the process. Any staff on an extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved in the unusual incident process will be trained to the workflow during their new hire probationary period.
Person responsible for corrective action is the project director. |
709.34 (a) (7) 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:
(7) Fire or structural damage to the facility.
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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 fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Revise unusual incident reporting policy to include documentation of physical assault or sexual assault by staff or a client, prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementation of a timely and appropriate corrective action plan, and reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policy will be revised by 6.1.22. The Project Director or designate will file a written and unusual incident report within 3 business days following the unusual incident. During the 90-day orientation period, new staff will be required to complete a web-based module on WellSpan's online reporting system. During the 90-day orientation period, new managers will need to complete web-based module on WellSpan's online reporting system, prior to being granted manager access in the reporting system. Reference guides are available to staff and managers, these guides review steps in entering a safety event and managing safety events. 100% of all staff involved or responsible for the reporting of unusual incidents will be educated and trained to the process. Any staff on an extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved in the unusual incident process will be trained to the workflow during their new hire probationary period.
Person responsible for corrective action is the project director. |
709.34 (a) (8) 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:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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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 an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Revise unusual incident reporting policy to include documentation of physical assault or sexual assault by staff or a client, prompt review and identification of the causes directly or indirectly responsible for the unusual incident, implementation of a timely and appropriate corrective action plan, and reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policy will be revised by 6.1.22. The Project Director or designate will file a written and unusual incident report within 3 business days following the unusual incident. During the 90-day orientation period, new staff will be required to complete a web-based module on WellSpan's online reporting system. During the 90-day orientation period, new managers will need to complete web-based module on WellSpan's online reporting system, prior to being granted manager access in the reporting system. Reference guides are available to staff and managers, these guides review steps in entering a safety event and managing safety events. 100% of all staff involved or responsible for the reporting of unusual incidents will be educated and trained to the process. Any staff on an extended leave of absence will receive training prior to working their next assigned shift upon returning from leave. Newly hired staff involved in the unusual incident process will be trained to the workflow during their new hire probationary period.
Person responsible for corrective action is the project director. |