INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Square One Health 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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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 facility fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
Facility has been open since June 26, 2024. There was no documentation of any fire drills from opening to time of inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director or designee will develop a spreadsheet and or Outlook calendar that will list monthly fire drill dates, times, overnight fire drill and information for the facility. In addition, Executive Director will assign someone from each shift to be responsible for following the fire drill schedule and proper documentation.
Executive Director, Residential Assistant Director will conduct quarterly audits of the fire drill logs to ensure the drill are completed correctly and within the timeframes. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop policies and procedures on client rights that included a client receiving care or treatment under section 7 of the act (71 P.S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Square One Health LLC, created an addendum to the current Client Right's policy and Square One Health Client Handbook with acknowledgment (signature) from client, will includes PA. 709.30 client's rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
Executive Director, Program Director or Designee will conduct quarterly inspections of charts to ensure that proper documentation and signatures are in compliance.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop policies and procedures on client rights that included the project may not discriminate in the provision of services on the basis of creed and marital status.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Square One Health LLC, created an addendum to the current Client Right's policy and Square One Health Client Handbook with acknowledgment (signature) from client, will includes PA. 709.30 client's rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
Executive Director, Program Director or Designee will conduct quarterly inspections of charts to ensure that proper documentation and signatures are in compliance.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop policies and procedures on client rights that included the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Square One Health LLC, created an addendum to the current Client Right's policy and Square One Health Client Handbook with acknowledgment (signature) from client, will includes PA. 709.30 client's rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
Executive Director, Program Director or Designee will conduct quarterly inspections of charts to ensure that proper documentation and signatures are in compliance.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop policies and procedures on client rights that included that the clients have the right to appeal a decision limiting access to their records to the director.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Square One Health LLC, created an addendum to the current Client Right's policy and Square One Health Client Handbook with acknowledgment (signature) from client, will includes PA. 709.30 client's rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
Executive Director, Program Director or Designee will conduct quarterly inspections of charts to ensure that proper documentation and signatures are in compliance.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop policies and procedures on client rights that included the clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Square One Health LLC, created an addendum to the current Client Right's policy and Square One Health Client Handbook with acknowledgment (signature) from client, will includes PA. 709.30 client's rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
Executive Director, Program Director or Designee will conduct quarterly inspections of charts to ensure that proper documentation and signatures are in compliance.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop policies and procedures on client rights that included that the clients have the right to submit rebuttal or memoranda to their own records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Square One Health LLC, created an addendum to the current Client Right's policy and Square One Health Client Handbook with acknowledgment (signature) from client, will includes PA. 709.30 client's rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
Executive Director, Program Director or Designee will conduct quarterly inspections of charts to ensure that proper documentation and signatures are in compliance.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the policy and procedure manual, the facility failed to include a policy and procedure for the inspection of storage areas.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
a. Inspection of Storage Area- Director of Nursing or assigned Nurses will conduct inspections of medications twice a day (day shift and night shift of uncontrolled medications) logging and signing off on them in the labeled Inventory book(binder) kept in the nurse's station. The Director of Nursing will conduct a quarterly inspection of the above process in the inspection book/binder on a separate sheet listed (quarterly inspection) to ensure that procedures and documentation are being followed.
b. All controlled medications shall be kept in a separate locked medication box/container. Nurses will count controlled substances twice a day (day shift and night shift) for accuracy and log in and sign off in the appropriate space for controlled substances.
c. All expired, damaged, and/or contaminated medications are segregated in the pharmacy until they are removed from the facility.
d. Loss, theft or Misuse of Medications and Controlled substances must be reported immediately to the Director of Nursing or Executive Director. Director of Nursing or Executive Director will in writing of the theft or significant loss of any controlled substance, disposal receptacles or listed chemicals within one business day of discovery of such loss or theft in an incident report. Additionally, such loss or theft shall be reported to the Drug Enforcement Administration and the appropriate state agency.
e. Copies of drug -related regulations will be available in all nursing stations for review.
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709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to include a policy and procedure for the security of drugs, including the loss or misuse of drugs.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
2. Storage/Accounting/Inspection of Medications
All medications will be stored in a locked cabinet that is accessible only by designated staff. A medication log sheet(s) will be maintained for each client in a designated logbook in which the medication name, number/amount of medication in container, information regarding dosage and frequency of use, instructions for use including method/route of administration, prescribing professional, and documentation of consumption of the medication will be recorded. All entries on the client medication log sheet(s) will be initialed by both staff and client to verify accuracy.
a. Inspection of Storage Area- Director of Nursing or assigned Nurses will conduct inspections of medications twice a day (day shift and night shift of uncontrolled medications) logging and signing off on them in the labeled Inventory book(binder) kept in the nurse's station. The Director of Nursing will conduct a quarterly inspection of the above process in the inspection book/binder on a separate sheet listed (quarterly inspection) to ensure that procedures and documentation are being followed.
b. All controlled medications shall be kept in a separate locked medication box/container. Nurses will count controlled substances twice a day (day shift and night shift) for accuracy and log in and sign off in the appropriate space for controlled substances.
c. All expired, damaged, and/or contaminated medications are segregated in the pharmacy until they are removed from the facility.
d. Loss, theft or Misuse of Medications and Controlled substances must be reported immediately to the Director of Nursing or Executive Director. Director of Nursing or Executive Director will in writing of the theft or significant loss of any controlled substance, disposal receptacles or listed chemicals within one business day of discovery of such loss or theft in an incident report. Additionally, such loss or theft shall be reported to the Drug Enforcement Administration and the appropriate state agency.
e. Copies of drug -related regulations will be available in all nursing stations for review.
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