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 11, 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. |
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 log for the months of December 2024 through December 2025, the facility failed to provide documentation of a fire drill being conducted the month of January 2025.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
the facility will conduct fire drills per month under the supervision of the Program Manager and Administrative Coordinator. Conducting fire drills bi-monthly will ensure compliance with monthly fire drill requirements and will provide a safeguard against missing a required drill due to staff absences, scheduling conflicts, or oversight. |