INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 15, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Base on a physical plant inspection conducted on August 15, 2023, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room. A video camera was observed to be mounted on the ceiling of a room utilized for group counseling sessions.
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Plan of Correction
The small room is not the main group counseling room but rather a multipurpose room that is infrequently used for group counseling sessions and much more often used for space for clients to socialize during free time, family visits and staff meetings. For the times that the room needs to be used for counseling sessions, the camera will be turned towards the wall and covered so that privacy is ensured. There is no sound, only video, provided by this camera. It is necessary to have a camera in this room to ensure the safety of clients, staff and visitors including minor children. The counselor facilitating the group will ensure that the camera is turned prior to the group start time. This will be reviewed with the clinical team during their team meeting on 8/30/2023 and monitored by the Clinical Supervisor. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the Medication Management policy, along with client and staff interviews conducted on August 15. 2023, the facility failed to implement the procedures for the administration of medication. One of five staff interviewed, and four of four clients interviewed reported that medication is being poured into the medication cup prior to the client presenting for their medications.
The Medication Management policy indicates that medications are to be administered at the time they are prepared, and medications are not to be pre-poured.
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Plan of Correction
The Program Director notified all nursing staff and reminded them that POWER's Medication Management policy indicates that medications are to be administered at the time they are prepared, and medications are not to be pre-poured.
The Clinical Director followed up with an email memo on 8/17/2023 reminding all staff that medications are never to be pre-poured and that anyone caught doing so will receive disciplinary action up to and including termination.
It is the responsibility of the staff, nurses and Program Director to ensure medications are never pre-poured and will be monitored by checking cameras and random medication time observations by program supervisors. |