INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 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, Nanticoke Medical Center, LLC 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of administrative documents, the facility failed to comply with the deadline provided at the time the inspection was scheduled with providing a plan documenting the qualifications and training of staff. These finding were reviewed with the facility staff at the time of the inspection.
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Plan of Correction
Going Forward All staff qualifications and training documentation will be kept onsite in the Facility staff folder and reviewed and updated on a quarterly basis at end of January, march, june, sept and November. This will be done by director. |
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's policy and procedures manual, the facility failed to prepare an annual update and sign a written manual delineating project policies and procedures. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Going forward there will be a signature log kept at the end of the policy manual and signed off annually end of December even if there are no changes. This will be the responsibility of facility Director. |