INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Women's Institute of Family Health 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 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection on July 21, 2025, the facility failed to ensure two exits on every floor. The facility is on the eighth floor of the building, and there is only one stairwell serving as the sole exit, from this floor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has submitted an application to DDAP for an exception for the two exit requirement
As of this date, the facility is still awaiting a ruling on our request for an exception for the two exit requirement. If an exception is not approved the facility will relocate to another location. The Executive Director has already begun contacting realtors to make inquiries about alternate office space and the Executive Director will be responsible for making sure that the facility is in full compliance by 10/31/2025 |
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 a review of client records, the facility failed to document an individualized treatment and rehabilitation plan was developed with the client within four weeks of admission, per the facility policy, in three of six applicable records reviewed.
Treatment plans were not individualized as the goals and supports were identical to those in the plan for other clients.
Client # 4 was admitted on February 18, 2025 and was discharged on May 30, 2025. The individual treatment and rehabilitation plan was completed on March 18, 2025; however, it was not individualized as the goals and supports were identical to those in the plans for Clients # 6 and 7.
Client # 6 was admitted on December 27, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 9, 2025; however, it was not individualized as the goals and supports were identical to those in the plans for Clients # 4 and 7.
Client # 7 was admitted on May 6, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 3, 2025; however, it was not individualized as the goals and supports were identical to those in the plans for Clients # 4 and 6.
This is a repeat citation from the July 6, 2023, and July 11, 2024, annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Board of Directors have approved and implemented a new policy that requires the Medical Director to review all treatment and rehabilitation plans on a weekly basis to assure that each plan is individualized.
The policy assigning this responsibility to the Medical Director has been added to the facility's standard operating procedures along with the responsibility to discipline staff who fail to comply with this policy. The Medical Director will submit monthly reports to the Board of Directors on the compliance status of client files and any staff disciplinary actions that include written warnings, suspension or termination for failure to comply with this policy. |
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 a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of six applicable records reviewed.
Client # 4 was admitted on February 18, 2025 and was discharged on May 30, 2025. The individual treatment and rehabilitation plan was completed on March 18, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on December 27, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 9, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on May 6, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 3, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Board of Directors approved a new policy assigning the task to the Medical Director of ensuring that treatment and rehabilitation plans includes the type and frequency of treatment. The policy has been added to the facility's standard operation procedures. The Medical Director will review client records on a weekly basis and will be responsible for the discipline of staff who fail to be incompliance with this regulation to include written warnings, suspension or termination. The Medical Director will submit monthly reports to the Board of Directors on compliance with this policy. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete individual treatment and rehabilitation plans was submitted and approved by the Department for the July 6, 2023, and July 11,2 024 licensing inspections. Failing to complete individual treatment and rehabilitation plans was again found to be a deficiency in the July 21, 2025, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Board of Directors has made adjustments to the job description of the Medical Director to include the responsibility for the oversight of all clinical records for accuracy and completion and also oversight and approval of plans of corrections. The Medical Director will be responsible for approving all Plans of corrections and clinical records. The Medical Director will monitor client records on a weekly basis and will directly supervise any actions that need to be taken to address any deficiencies and will also be responsible for any staff disciplinary action for failure to comply with facility policies. The Medical Director will submit written monthly reports to the Board of Directors at meetings on the status of clinical records, the outcome of Plans of Corrections and any staff disciplinary actions that were taken due to non compliance of facility procedures. |