INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9-10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Organization for Women in Early Recovery (POWER) 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the personnel training records, the facility failed to have the project director complete at least 12 clock hours of annual training in one of one record. Staff #1 was hired as the project director on September 1, 1992. Staff #1 had documented eight hours of training for the July 1, 2024 through June 30, 2025 training year.This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the annual inspection conducted on December 12, 2024.
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Plan of Correction
It is understood that the Project Director position requires 12 hours of training per year. Due to this repeat citation, training for the Project Director will now be tracked throughout the training year by the agency Training Specialist. The Training Specialist will provide the Project Director with an update at the end of each quarter as to the number of training hours accumulated thus far for the training year to ensure hours are attended prior to the end of the training year. This will begin on December 31, 2025 and will be ongoing each quarter. The Project Director is responsible to attending the required 12 hours of training. |
709.92(a) 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:
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client in three of six records. The facility ' s policy states that the treatment plan will be developed within thirty days of admission.Client #8 was admitted to outpatient on May 22, 2025 and was discharged on July 9, 2025. The comprehensive treatment and rehabilitation plan was due no later than June 22, 2025; however, this was not completed prior to discharge.Client #10 was admitted to outpatient on December 27, 2024 and was discharged on May 30, 2025. The comprehensive treatment and rehabilitation plan was due no later than January 27, 2025; however, this was not completed until February 3, 2025.Client #12 was admitted to outpatient on June 5, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was due no later than July 7, 2025; however, this was not completed until July 11, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is understood that POWER New Day staff are expected to follow the policies as they are written and explained. After consulting with the monitoring specialist, reviewing the current policy, and considering the current patterns and needs of the clients served at POWER New Day, the policy will be revised to state the master treatment plan will be completed by the end of the 4th individual session from the intake date and replace the previously stated first 30 days of service. This will take into account the clients' attendance patterns and allow for a consistent number of sessions for all clients that can focus on treatment planning. The program director and/or lead therapist will audit/review 1 client record per therapist per week to ensure that treatment plans are being completed and submitted on time. The audit results will be reviewed with the therapist regularly in their weekly supervision. This will begin on December 29, 2025. |