INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2023 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 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The facility ' s fire extinguishers were last inspected in November of 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Residential Support Specialist will perform a weekly walk thru. The walk thru consists of performing various safety checks including the fire extinguishers.
Program Director will ensure the weekly walk thru documentation is completed and accurate. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the client records, the facility failed to notify an emergency contact of a client who discharged in one applicable record. Client #1 was admitted to inpatient on May 31, 2023 and discharged on September 5, 2023. There was not documentation that the emergency contact was notified.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
POWER House Daily Census now consists of a emergency contact notified column.
This daily census is reviewed daily by the Senior Administrative Assistant and weekly by the Program Director.
All staff have been trained on how to properly notify an emergency contact.
On call is notified of an afa. The on call is also required to ensure an emergency contact has been notified |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information and discussion with staff, the facility failed to provide documentation that the inspections of storage areas were completed per program policy. The facility ' s policies and procedures state that inspections are to be completed quarterly. The facility was unable to provide documentation of the inspections completed from January 2023 to November 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PD will review PH Maintenance log weekly.
Upon review the PD will ensure that inspections of storage areas are being completed.
The Senior Administrative Assistant will perform weekly audits to ensure storage area inspections are being completed.
SAA will alert PD if inspections are not being completed. |
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 manual in four of seven applicable records. The project policy and procedure manual indicated an initial comprehensive treatment and rehabilitation plan be completed within fifteen days of admission into the program.Client #1 was admitted to inpatient on May 31, 2023 and discharged on September 5, 2023. An initial comprehensive treatment plan was due no later than June 14, 2023, however this was not completed until June 23, 2023.Client #3 was admitted to inpatient on April 4, 2023 and discharged on September 25, 2023. An initial comprehensive treatment plan was due no later than April 19, 2023, however this was not completed until June 23, 2023.Client #4 was admitted to inpatient on July 14, 2023 and discharged on October 30, 2023. An initial comprehensive treatment plan was due no later than July 29, 2023, however this was not completed until August 3, 2023.Client #5 was admitted to inpatient on June 29, 2023 and was still active at the time of the inspection. An initial comprehensive treatment plan was due no later than July 14, 2023, however this was not completed until August 1, 2023.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical staff have been trained on proper documentation deadlines.
The Program Director reviews new hire paperwork upon completion and within the required deadlines. This will remain in effect until Program Director is confident that staff is able to complete documentation within the required timeframes.
The PH Daily Census includes documentation deadlines that is reviewed by Senior Administrative Assistant daily. SAA will alert Program Director if documentation has not been completed within the required timeframes.
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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 four of seven applicable records.Client #1 was admitted to inpatient on May 31, 2023 and discharged on September 5, 2023. A treatment and rehabilitation plan was developed on June 23, 2023. A treatment and rehabilitation plan update was due no later than July 23, 2023, but was not completed until August 1, 2023.Client #4 was admitted to inpatient on July 14, 2023 and discharged on October 30, 2023. A treatment and rehabilitation plan was developed on August 3, 2023. A treatment and rehabilitation plan update was due no later than September 3, 2023, but was not completed until September 12, 2023.A treatment and rehabilitation plan was developed on September 12, 2023. A treatment and rehabilitation plan update was due no later than October 12, 2023, but was not completed until October 15, 2023.Client #5 was admitted to inpatient on June 29, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 1, 2023. A treatment and rehabilitation plan update was due no later than September 1, 2023, but was not completed until September 12, 2023.Client #6 was admitted to inpatient on June 13, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 17, 2023. A treatment and rehabilitation plan update was due no later than September 17, 2023, but was not completed until September 22, 2023.A treatment and rehabilitation plan was developed on September 22, 2023. A treatment and rehabilitation plan update was due no later than October 22, 2023, but was not completed until October 24, 2023.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the December 6, 2022 annual licensing inspection.
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Plan of Correction
All Clinical staff have been trained on the required deadlines for treatment plan reviews.
The Program Director will review the PH daily census weekly which includes treatment plan review due dates. The Program Director will review the client charts with treatment plan reviews to ensure they are completed.
The Senior Administrative Assistant will also review the PH Daily Census daily (which includes due dates) to alert the PD of treatment plan reviews to ensure they are being reviewed. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records and discussion with staff, the facility failed to document work done by the client at the project in the treatment plan in seven of seven clients records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PD has trained PH clinical staff to include Daily chores in treatment plans.
PD will review all Master treatment plans after completion to ensure clinical staff is documenting correctly.
PD will review treatment plan reviews to ensure the Daily chores continue to be documented.
PD performs monthly chart audits. |