INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 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 (Power) 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 an unannounced fire drill at least once a month. Fire drills were reviewed for the time period of March 2022 through November 2022.
There was no fire drill documented for the month of July 2022.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 20, 2020, January 21, 2021 and the February 28, 2022 licensing inspections.
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Plan of Correction
Together RSS Lead and SR AA will make certain that all staff are trained and monthly drills are being conducted accordingly. Sr. AA will conduct reviews of the fire drill binder by the 25th of each month to ensure compliance and permit sufficient time to conduct a drill if one was missed. |
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 logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. Fire drills were reviewed for the time period of March 2022 through November 2022.
There were no fire drills during sleeping hours documented.
Fire drills were reviewed for the time period of March 2022 through November 2022.
This is a repeat citation from the February 28, 2022 licensing inspection.
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Plan of Correction
RSS Lead and SR. AA will make certain that all staff are trained and fire drills are being conducted during the hours of 11:00pm-5:00am. Sr. AA will conduct monthly revies of the fire drill binder to ensure compliance.
All RSS staff will be trained by 1/30/23. RSS Lead and SR. AA must sign off on their training. |
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 a review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of seven client records reviewed.
Client #1 was admitted on April 20, 2022 and was still active at the time of the inspection. A treatment plan update was completed on October 5, 2022 and the next update was due no later than November 5, 2022; however, it was not completed until November 10, 2022.
Client #3 was admitted on May 10, 2022 and was still active at the time of the inspection. A treatment plan update was completed on September 2, 2022 and the next update was due no later than October 2, 2022; however, it was not completed until November 9, 2022.
Client #5 was admitted on March 31, 2022 and was discharged June 2, 2022. A treatment plan update was completed on April 5, 2022 and the next update was due no later than May 5, 2022; however, none was completed.
Client #6 was admitted on March 10, 2022 and was discharged June 3, 2022. A treatment plan update was completed on April 14, 2022 and the next update was due no later than May 14, 2022; however, none was completed.
Client #7 was admitted on March 14, 2022 and was still active at the time of the inspection. A treatment plan update was completed on June 1, 2022 and the next update was due no later than July 1, 2022; however, it was not completed until July 7, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical team will discuss and review treatment plans during supervision at least 1x per month to make certain that treatment plans are updated within the regulatory timeframe for all clients. Quarterly audits are completed by the Program Director to ensure all charts are in compliance.
All Clinical staff have been trained on the importance of treatment plans being completed within regulatory timeframes.
Treatment Plans for client's 1,3,& 7 are all within compliance currently. Client's 5 & 6 were discharged therefore they do not have any further treatment plans to update. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include case consultation notes in two out of four applicable records reviewed.
Client #3 was admitted on May 10, 2022 and was still active at the time of the inspection.
Client #7 was admitted on March 14, 2022 and was discharged on September 23, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case consultations have been added to Clinical Team meeting agenda. These meetings occur weekly. During these clinical meetings all clients will be reviewed to ensure Case consultations are being completed within every 90 days. All clinical staff have been trained on regulatory timeframes for case consultations.
Monthly chart audits will be performed by the clinical supervisor to ensure all case consultations are being completed every 90 days. Program Director will perform quarterly audits as well.
Client 3 has a current case consultation and is within compliance. Client 7 has been discharged. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary within 7 days following discharge per the facilites policy and procedure, in one out of three applicable records reviewed.
Client #7 was admitted on March 14, 2022 and was discharged on September 23, 2022. The discharge report was completed on November 21, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff have been trained on regulatory timeframes for discharge summaries. Discharges have been added to the Clinical meeting agenda which occurs weekly. This will ensure that the discharge summaries are being completed within 7 days of discharge.
Monthly chart audits will be conducted by the clinical supervisor to ensure that all charts are within compliance within the applicable chapters of 28 PA Code.
Program Director also performs quarterly chart audits to ensure compliance as well.
Client 7 does now have a discharge summary although it is not within 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 fire drill logs, the facility failed to comply with plans of correction that were approved by the Department.
Plan of corrections for fire drills were submitted and approved by the Department for the January 20, 2020, January 21, 2021 and the February 28, 2022 annual licensing inspections. Fire drills were again found to be a deficiency in the December 6, 2022 licensing inspection as a fire drill was not completed in July, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This facility will ensure that all personnel on shifts are trained to perform assigned tasks during emergencies and drills. All RSS staff will be retrained by 1/30/23. RSS Lead and SR. AA must sign off on their training. Also, staff must review the fire drill binder monthly to ensure that monthly fire drills are occurring and that staff are maintaining an accurate written fire drill including the date, time, amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
Together RSS Lead and SR AA will make certain all staff are trained by 1/30/23 and have continued training as needed. SR AA will conduct reviews of the fire drill binder by the 25th of each month to ensure compliance and permit sufficient time to conduct a fire drill if one was missed. |