INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 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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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 one of one 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 in client record # 1.
Client # 1 was admitted on November 8, 2022 and was still active at the time of the inspection. A review of client records and discussion with facility administration indicated funding was being provided however, there was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source. Also, a correspondence with a physician documented on November 8, 2022 without an informed and voluntary consent from the client for the disclosure of information in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the expectation that SUD Release of Information Forms are obtained for all PCP correspondence and payors upon intake and when there are changes to PCP or payor. This will be reviewed with team members on 1/10/23 at a scheduled staff meeting. Any staff member on extended leave of absence will recieve training prior to working their next assigned shift upon returning from leave. Newly hired staff responsible for obtaining SUD Release of Information Forms will be trained to the workflow during their new hire probationary period. This will be added to onboarding checklist so new team members are aware of this expectation. Clinical team lead will audit SUD charts monthly over the next three monts to ensure compliance.
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% or greater compliance has been achieved for three consecutive months. |
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 an event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from the March 24, 2022 annual licensing inspection.
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Plan of Correction
Policy addressing 709.34 Reporting of Unusual Incidents has been updated by Project Director on 12/30/22 to include site specific responses 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. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on one of one client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services.
Client # 1 was admitted on November 8, 2022 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on December 6, 2022 however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans will include type and frequency of treatment and rehabilitation services along with any proposed services. Clinical team lead will educate clinical staff by 1/17/23. 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 chart documentation of type and frequency of treatment and rehabilitation services to include proposed services will be trained to the workflow during their new hire probationary period. This will be added to onboarding checklist so new team members are aware of this expectation. Clinical team lead will audit SUD charts monthly over the next three months to sure compliance. Monitoring results will be reported monthly to the Quality Management Committee by Manager, Licensure and Accreditation, or designee. Corrective actions will be determined effective after 90% or greater compliance has been achieved for three consecutive months. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on one of one client records reviewed, the facility failed to provide documentation of a complete client record to include client related correspondence in client record # 1.
Client # 1 was admitted on November 8, 2022 and was still active at the time of the inspection. A review of client records and discussion with facility staff indicated funding was provided from an outside entity however, there was no documentation of correspondence with the outside entity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the expectation that SUD Release of Information Forms are obtained for all payors upon intake and when there are changes to payor. This will be reviewed with team members on 1/10/23 at a scheduled staff meeting. 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 obtaining SUD Release of Information Forms will be trained to the workflow during their new hire probationary period. This will be added to onboarding checklist so new team members are aware of this expectation. Clinical team lead will audit SUD charts monthly over the next three months to ensure compliance.
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% or greater compliance has been achieved for three consecutive months. |