INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 29, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Way Of Life 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:
|
Plan of Correction
|
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on applicable staff records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations reviewed and signed by the employee in one of three records. The facility ' s policy and procedure manual states annual written individual staff performance evaluations will be completed by each staff ' s hire date annually.
Staff #1 was hired as the project director on September 26, 2022. An annual performance evaluation was due to be completed by September 26, 2024, however this was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
To ensure 709.26(b) 3 Personnel management and to prevent continued lapse in any employee's annual review, the electronic employee management system will send a reminder 30 days prior to the due date of an employee evaluation and will be tracked and monitored by Corporate Director of Administration to ensure current and future performance evaluation 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.
|
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 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 to contact the emergency contact.
Client #2 was admitted to the residential level of care on January 7, 2025, and discharged on February 11, 2025. There was a consent for the emergency contact in client #2 ' s record.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
On 8/6/25 clinical and monitor received retraining on AMA procedures and the need to contact emergency contacts within 12 hours of discharge. Training included specifics in regards to informed and voluntary consents especially in the area of purpose of disclosure, as well as specific information that could be released for an informed and voluntary consent. To ensure future compliance consents will be reviewed during monthly chart reviews completed by the Firetree compliance team. |