INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 15, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Women's Institute for Family Health was found to not 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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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the projects policy and procedure manual, the project failed to provide procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project director will develop a plan for responding to a physical assault or sexual assault by staff or a client by 4/18/2021; the plan will be included in the policy and procedure manual; project staff will be trained by the Director on this policy |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the projects policy and procedure manual, the project failed to develop and implement procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director will develop and implement procedure in responding to selling or use of illicit drugs on the premises. The policy will be included in the procedure manual and staff will be trained on the policy. To be completed by 4/18/2021. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the projects policy and procedure manual, the project failed to develop and implement procedures in responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director will develop and implement a policy for responding to trauma, suicide, medication error or unusual circumstances while in the outpatient facility or when known by the facility for ambulatory services. The policy will be included in the procedure manual and staff will be trained by the Director on this policy. To be completed by 4/18/2021 |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the projects policy and procedure manual, the project failed to develop and implement procedures in responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director will develop and implement procedures in response o significant disruption of services due to fire, storm, flood or other occurrence which closes the facility for more than 1 day. The procedure will be included in the procedure manual. The Director will train staff on the procedure. To be completed by 4/18/2021 |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the projects policy and procedure manual, the project failed to develop and implement procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director will develop a procedure for responding to theft, burglary, break in or similar incident at the facility. The procedure will be included in the procedure manual. The Director will train staff on the procedure. To be implemented by 4/18/2021 |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the projects policy and procedure manual, the project failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director shall develop and implement a procedure for responding to the facility requiring the presence of police, fire or ambulance personnel. The procedure will be included in the procedure manual. The Director will train staff on the procedure. To be completed by 4/18/2021. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the projects policy and procedure manual, the project failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director shall develop and implement a policy for responding to fire or structural damage to the facility. The policy will be included in the procedure manual. The Director will train staff on the procedure. To be completed by 4/18/2021 |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the projects policy and procedure manual, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director shall develop and implement a policy to respond to an outbreak of contagious disease requiring Center for Disease Control (CDC) notification. The procedure will be included to the procedure manual. The Director shall train staff on the procedure. To be completed by 4/18/2021 |