INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2021 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the January - December 2020 fire drill records, the facility failed to document an unannounced fire drill for November 2020.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 2020 licensing inspection.
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Plan of Correction
Throughout November 2020, POWER House was instructed by Allegheny County Health Department to isolate residents from one another due to positive cases of COVID-19 identified in five current residents. During this month, our regular unannounced fire drill was not conducted in order to maintain resident separation in accordance with Quarantine and Isolation protocols for COVID-19. In the future, Program Manager will consult with DDAP prior to modifying the current fire drill procedures to ensure compliance. The Program Manager has reviewed the Fire Drill requirements with the RSS Supervisor, who is responsible for making sure drills are conducted monthly as per current policy. The current policy will continue which is to conduct a fire drill on each shift (daylight, evening and overnight) once per month. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records the facility failed to document the name of the person, agency or organization to whom disclosure was made in two of seven client records reviewed on January 21, 2021.
The consent to release information form for funding was obtained during the intake process and did not include the name of the client's insurance's company.
Client # 5 was admitted August 28, 2020 and discharged December 8, 2020.
Client # 7 was admitted October 30, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/29/21, Program Manager contacted POWER committee responsible for approving and implementing changes in our Electronic Medical Records requesting the name of the client's funding entity is added to the Consent to release information. This will be fixed in the EMR by 2/26/21. To avoid additional errors while the records are being corrected, the Resource Coordinator will be trained by Clinical Lead in manually entering alternative funding sources on funding releases by 2/12/21. Clinical Lead will be responsible for ongoing monitoring of correct completion of Consents and will be reviewed with Program Manager when errors are identified for staff development. |