INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9, 2024, 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) (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 fire drill logs the facility failed to maintain a written fire drill record including: exit route used.
A review of ten months of fire drill logs, from January 2024 - October 2024, revealed that the facility is not documenting the exit route used during each evacuation.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director or designee will provide education on requirements to those responsible for completion of fire drills by 12/19/2024. All existing employees who are responsible for the documentation of Fire Drill reports will be educated to the requirement annually by the Project Director or designee. Those employees who are on extended leave, such as FMLA, who return after 12/19/2024 will be educated to the documentation requirement prior to their next assigned shift by the Project Director or Designee. Fire Drill Monitoring results will be submitted monthly by the Project Manager or designee to the Quality Management Council. The corrective action plan will be determined effective after 3 consecutive reporting periods of 100% compliance have been achieved. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs the facility failed to prepare alternate exit routes to be used during fire drills.
A review of ten months of fire drill logs, from January 2024 - October 2024, revealed that the facility is not documenting the use of alternate exit routes.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director or designee will provide education on requirements of alternative exit routes to those responsible for completion of fire drills by 12/19/2024. All existing employees who are responsible for fire drills will be educated to the requirement annually by the Project Director or designee. Those employees who are on extended leave, such as FMLA, who return after 12/19/2024 will be educated to the documentation requirement prior to their next assigned shift by the Project Director or Designee. Monitoring will be submitted to Quality Management Council by the Project Director or designee. The corrective action plan will be determined effective after 3 consecutive reporting periods of 100% compliance have been acheived. |
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 the review of client records, the facility failed to document 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, the purpose of the disclosure.
Client #3 was admitted on October 9, 2024, and was still an active client at the time of the inspection. A consent form dated October 11, 2024, for an insurance provider, did not include documentation of the purpose of the release.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Team members will be educated and review fully complete Releases of Information during an all staff meeting on 1/15/2025 by the Project Director or designee. The Releases of Information example from the staff meeting will also be sent electronically to all staff and placed electronically on our Teams channel on 01/15/2025. New staff will be trained to the requirement during orientation by the Project Director or designee. Those staff who are responsible for the completion of Release of Information who may be on Paid Time Off or extended leave will be educated to requirements upon their return by the Project Director or designee prior to their next assigned shift. Monitoring will be completed for fully completed Releases of Information starting in January 2025. Monitoring results will be reported monthly to the Quality Management Council by the Project Director or designee until sustained compliance is obtained. The corrective action plan will be determined effective after 3 consecutive reporting periods of 100% compliance have been achieved. Prior to next appointment, updated release of information will be obtained by therapist or designee. This will be audited by clinical team lead or designee by 1/30/24. Release of information in file that does not have purpose checked will be removed from patient's file |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in two of three applicable records reviewed.
Client #1 was admitted on June 24, 2024, and was still active at the time of the inspection. A treatment plan update was completed on September 27, 2024, and the next update was due no later than November 27, 2024; however, the next update was completed on November 29, 2024.
Client #5 was admitted on April 26, 2024, and discharged on December 6, 2024. A treatment plan update was completed on April 29, 2024, and the next update was due no later than June 29, 2024; however, it was completed on July 8, 2024; The next treatment plan update was due no later than September 8, 2024; however there was no documentation of further treatment plan updates.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Therapist will track and update caseload to ensure updates to treatment plans are made. Program Therapist will add encouters to note why changes where not made in a timely manner if these updates were missed. This change to treatment plans will be communicated with staff during Clinical Supervision on 01/07/2025 by the Clinical Lead or designee. This requirement has been added to the Onboarding Checklist 12/13/2024. New staff will be trained to the requirement during orientation by the Project Director or designee. Those staff who are responsible for the completion of treatment plan updates who may be on PTO, FMLA or extended leave will be educated to requirements upon their return by the Project Director or designee prior to their next assigned shift. Monitoring will be completed for treatment plan updates starting in January 2025. Monitoring results will be reported monthly to the Quality Management Council by the Project Director or designee. The corrective action plan will be determined effective after 3 consecutive reporting periods of 100% compliance have been achieved. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of five applicable records reviewed.
Client #1 was admitted on June 24, 2024, and was still active at the time of the inspection. The treatment plan dated July 15, 2024, required two group therapy sessions per week for a total of three hours. There was no documentation of the client receiving group therapy during the week of August 4-10, 2024.
Client #5 was admitted on April 26, 2024, and was discharged on December 6, 2024. The treatment plan dated July 8, 2024, required two group therapy sessions per week for a total of three hours. During the weeks of September 1-7, 2024, and September 15-21, 2024, only one group session was documented in the client record.
Client #6 was admitted on August 28, 2024, and was discharged on October 21, 2024. The treatment plan dated August 29, 2024, required two group therapy sessions per week for a total of three hours. During the week of September 15-21, 2024, only one group session was documented in the client record.
Client #7 was admitted on August 14, 2024, and was discharged on October 31, 2024. The treatment plan dated August 19, 2024, required two group therapy sessions per week for a total of three hours. During the week of September 8-14, 2024, only one group session was documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Group note documentation compliance and process will be fully reviewed during the Prisons Programs Clinical Meeting on 12/20/2024 by the Social Services Specialist/Clinical Lead. The process will be posted in our Teams channel for access on 01/15/2025. New staff will be trained to the requirement during orientation by the Project Director or designee. Those staff who are responsible for the completion of group note documentation who may on PTO, FMLA or extended leave will be educated to requirements upon their return by the Project Director or designee prior to their next assigned shift. Monitoring will be complete for group note documentation starting in month January 2025. Monitoring results will be reported monthly to the Quality Management Council by the Project Director or designee. The corrective action plan will be determined effective after 3 consecutive reporting periods of 100% compliance have been achieved. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation note within guidelines established by the facility's policy and procedures manual, in three out of three applicable records reviewed. The facility's policy and procedures manual states a case consultation must be completed every sixty days following admission.
Client #1 was admitted on June 24, 2024, and was still active at the time of the inspection. A case consultation was due no later than August 24, 2024; however, there was no documentation of a completed case consultation in the client record.
Client #5 was admitted on admitted on April 26, 2024, and discharged on December 6, 2024. A case consultation was due no later than June 24, 2024; however, there was no documentation of a completed case consultation in the client record.
Client # 7 was admitted on admitted on August 14, 2024, and discharged on October 31, 2024. A case consultation was due no later than October 14, 2024; however, there was no documentation of a completed case consultation in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The case consultation timeline compliance and process will be fully reviewed during the Clinical Meeting on 01/07/2025 by the Clinical Lead. Program Therapist will prepare and review case consults during individual supervision, rounding or clinical supervision. Case consults will happen in conjunction with treatment plan updates. The process will be posted in our Teams channel for access on 01/15/2025. New staff will be trained during orientation by the Project Director or designee. Those staff who are responsible for the completion of case consultations who may on PTO, FMLA or extended leave will be educated on requirements upon their return by the Project Director or designee prior to their next assigned shift. Monitoring will be completed for case consultations starting in January 2025. Monitoring results will be reported monthly to the Quality Management Council by the Project Director or designee. The corrective action plan will be determined effective after 3 consecutive reporting periods of 100% compliance have been achieved. |