INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Angels Light Half Way House, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on applicable personnel records reviewed, the facility failed to provide documentation of six months supervision in one of one record. Per regulation, a counselor assistant with high school diploma or GED equivalent may counsel clients only under the direct observation of a trained counselor or clinical supervisor for at the first three months of employment. For the next nine months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or clinical supervisor.
Staff #4 was hired as a counselor assistant on October 7, 2024. Based on a review of Staff #4 ' s personnel record, there was no documentation of direct observation being conducted from October 17, 2024 through March 21, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will be providing direct supervision to the counselor assistant for a period of three months until 7/30/25, to ensure that she is meeting the qualifications of the position and that the facility is in compliance. This will be tracked through supervision notes that will be completed by the facility director. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of a complete medication administration record (MAR) in four of seven applicable records.
Client #1 was admitted on December 30, 2024 and was still active at the time of the inspection. Starting on February 1, 2025, a medication was to be given "take 1 tab at bed." The MAR documented that the medication was given at 9:00pm. There was no documentation of this medication given at 9:00pm on February 28, 2025.
Client #3 was admitted on February 6, 2025 and was still active at the time of the inspection. Starting on March 3, 2025 and discontinuing on March 11, 2025, a medication was to be given "take 1 cap every 6 hours until gone." The MAR documented that the medication was given at 8:00am, 4:00pm, and 9:00 pm. There was no documentation of this medication given at 4:00pm on March 5, 2025, March 6, 2025, and March 7, 2025. There was also no documentation that this medication was given at 9:00pm on March 20, 2025.
There was no MAR documented for the month of February 2025 for Client #3.
Client #5 was admitted on November 20, 2024 and discharged on February 28, 2025. Starting on January 20, 2025, a medication was to be given "take 1 cap at twice daily. " The MAR documented that the medication was given at 8:00am and 9:00pm. There was no documentation of this medication given at 8:00am on January 31, 2025. There was also no documentation of this medication given at 9:00pm on January 21, 2025, January 30, 2025, and January 31, 2025.
Client #7 was admitted on December 26, 2024 and discharged on January 29, 2025. There was no MAR documented for the month of January 2025 for Client #7.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 9, 2025 and April 24, 2024 licensing inspections.
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Plan of Correction
The facility director has trained the staff on how to properly document a MARS sheet, so that a reason is shown as to why the client missed their medication. The facility director will also be scanning all MAR sheets into the charts to ensure that there are none missing. The facility director will complete weekly chart audits to ensure compliance. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in one of one applicable record.
The facility's inpatient non-hospital residential policy and procedure states the client ' s emergency contact will be notified within 12 hours of the client ' s decision to leave against facility advice, providing there is consent given in writing for facility to make contact.
Client #4 was admitted to the residential level of care on January 20, 2025 and discharged on March 7, 2025.
There was a consent for the emergency contact in client #4 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility director is retraining all staff on the procedure of contacting an emergency contact when a client leaves against facility advice. All clients should have an emergency contact consent in their client file. If a client leaves against facility advice, and has consent in their file, staff will call their emergency contact to inform them of the client's departure. A case note will be submitted in the client's file to show that this occurred. The facility director will audit charts weekly to ensure compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 applicable client records reviewed, the facility failed to provide an initial comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure in three of seven records.
The project policy and procedure indicated an initial comprehensive treatment and rehabilitation plan be completed within five days of admission into the program.
Client #1 was admitted on December 30, 2024 and was still active at the time of the inspection. An initial comprehensive treatment plan was due no later than January 5, 2025, however this was not completed until February 17, 2025.
Client #5 was admitted on November 20, 2024 and discharged on February 28, 2025. An initial comprehensive treatment plan was due no later than November 25, 2024, however this was not completed until December 3, 2024.
Client #7 was admitted on December 26, 2024 and discharged on January 29, 2025. An initial comprehensive treatment plan was due no later than December 31, 2024, however this was not completed prior to discharge.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility director has ensured that all clinical staff are aware of having the initial treatment plans completed within 5 days of the client arriving to the facility per the policy and procedure manual. The facility director will audit charts weekly to ensure compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in two of five applicable records.
Client #4 was admitted to the residential level of care on January 20, 2025 and discharged on March 7, 2025. A treatment and rehabilitation plan was developed on January 20, 2025. A treatment and rehabilitation plan update was due no later than February 20, 2025, but was not completed until February 25, 2025.
Client #5 was admitted on November 20, 2024 and discharged on February 28, 2025. A treatment and rehabilitation plan was developed on December 3, 2024. A treatment and rehabilitation plan update was due no later than January 3, 2025, but was not completed until February 10, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has provided all clinical staff with the proper timeline of completing treatment plan updates and will conduct chart audits to ensure they are completed every 30 days. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure in two of three records.
The policy and procedure indicates follow-up contact must be made within five, thirty, ninety, and one hundred and eighty days after discharge.
Client #4 was admitted to the residential level of care on January 20, 2025 and discharged on March 7, 2025. The five day follow-up contact was due to be completed no later than March 12, 2025, however this was not completed until April 6, 2025.
Client #5 was admitted on November 20, 2024 and discharged on February 28, 2025. The five day follow-up contact was due to be completed no later than March 5, 2025. There was no documentation of follow-up contact being completed in the record.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 9, 2025 and April 24, 2024 licensing inspections.
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Plan of Correction
The discharge coordinator will complete follow-up calls for the appropriate time periods for each client, which will be documented in the client's chart. The facility director will audit the charts weekly to ensure compliance. |
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 documentation of a complete medication administration record (MAR) was submitted and approved by the Department for the January 9, 2025 and April 24, 2024 licensing inspections. Documentation of a complete medication administration record (MAR) were again found to be a deficiency in the April 30, 2025 annual licensing inspection.
A plan of correction for follow-up contact was submitted and approved by the Department for the January 9, 2025 and April 24, 2024 licensing inspections. Follow-up contact was again found to be a deficiency in the April 30, 2025 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will review all citations from the DDAP audits as well as the plans of corrections that the facility has made with the entire staff to ensure that they have been re-educated on ALL of the regulations.
Facility director has ensured that a training was completed on the MARS sheets, we are in the process of switching pharmacies to have improved MARS sheets, and the facility director will be uploading all MARS sheets in client charts to ensure that none are missing. The facility director will do chart audits weekly to maintain compliance. |