INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21 and February 28, 2022 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 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 fire drill logs, the facility failed to document unannounced fire drills at least once a month.Fire drills were reviewed for the time period of January 2021 - January 2022. There was no fire drill documented for the month of August 2021.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 21, 2021 and January 30, 2020 licensing inspection.
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Plan of Correction
The Program Manager has updated the "Fire Drill Management Policy" and re-trained all applicable staff members on or before 3/18/22. Manager reviewed in detail with the Admin Assistant who schedules two fire drills per month. Drills are conducted by staff on shift during the scheduled drill and will be reviewed by the 25th of each month by the Supervisor to ensure that if a drill has not yet been conducted for any reason, that there is still sufficient time to conduct a drill. Supervisor will then be responsible for scheduling and follow up to ensure the drill was completed as planned. All staff involved have been re-educated on the importance of conducting drills as they are scheduled and also recording any instances that result in an unplanned drill. The Supervisor is responsible for maintaining the completed fire drill tracking form and ensuring that the fire drill form was completed in its entirety for each drill with original form kept in Fire Drill binder in Program Manager's office. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.The fire drill logs for the period of January 2021 - January 2022 were reviewed. The only fire drill conducted during sleeping hours was documented in July 2021. There was a fire drill documented in January 2021; however, it was not documented whether it was AM or PM. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Manager has updated the "Fire Drill Management Policy" and re-trained all applicable staff members on or before 3/18/22. Manager reviewed in detail with the Admin Assistant who schedules two fire drills per month including one drill on overnight shift during sleeping hours at least once every six months. Drills are conducted by staff on shift during the scheduled drill and will be reviewed by the 25th of each month by the Supervisor to ensure that if a drill has not yet been conducted for any reason, that there is still sufficient time to conduct a drill. Supervisor will then be responsible for scheduling and follow up to ensure the drill was completed as planned. All staff involved have been re-educated on the importance of conducting drills as they are scheduled and also recording AM or PM clearly on the form. The form has been revised so that there is a place for AM/PM that should make this less likely to be left off. The Supervisor is responsible for maintaining the completed fire drill tracking form and ensuring that the fire drill form was completed in its entirety for each drill with original form kept in Fire Drill binder in Program Manager's office. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
709.17(a)(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. Based on a review of the fire drill logs, the facility failed to comply with plans of correction approved by the Department. A plan of correction for fire drills was submitted and approved by the Department for the January 21, 2021 and January 30, 2020 annual licensing inspections. Fire drills were again found to be a deficiency in the January 21 and February 28, 2022, licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan(s) of correction for the fire drill issues were completed by Program Manager/Facility Director with the help and oversight of the agency Clinical Director to ensure that the Manager is in full understanding of the POCs and the importance that it is followed in its entirety. The Facility Director/Program Manager will be required to report on the progress maintaining the approved POCs to the Clinical Director on a monthly basis, beginning in March 2022, during supervision sessions to ensure the POCs are being followed. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of two client records.Client #5 was admitted on May 27, 2021 and successfully discharged on January 14, 2022. There was no aftercare plan documented for client #5.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director/Program Manager completed a "Discharge Process" re-training for all clinical team members on 3/11/2022. The training included a review of the Aftercare plan requirement and a reminder that an Aftercare plan must be completed for all planned discharges. The clinical team was provided with a "discharge checklist" tool to help them ensure they have completed all required items for discharge including the Aftercare Plan. The Clinical Supervisor will conduct clinical files review each month to ensure that this process is happening consistently and follow-up as needed with individual team members in supervision sessions. Findings from these clinical file reviews are reported to the Clinical Director on a quarterly basis as part of the QA Plan. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a 30 day follow up as per agency policy in one of two client records.Client #4 was admitted on August 9, 2021 and discharged on November 6, 2021. There was no follow up documented for client #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director/Program Manager completed a "Discharge Process" re-training for all clinical team members on 3/11/2022. The training included a review of the process for assigning clients to the "POWER House Follow-up group" in the electronic health record which is how follow-ups are scheduled and conducted by the follow-up team. The clinical team was provided with a "discharge checklist" tool to help them ensure they have completed all required items for discharge including the assignment to the follow-up group. The Clinical Supervisor will conduct clinical files review each month to ensure that this process is happening consistently and follow-up as needed with individual team members in supervision sessions. Findings from these clinical file reviews are reported to the Clinical Director on a quarterly basis as part of the QA Plan. |