INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MPower Wellness of Pennsylvania 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the 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.
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Observations
Based on a review of the written fire drill record from December 2022 to June 2023, the facility failed to include which exit route was used and whether the fire alarm or smoke detector was operative for each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has updated the current fire drill record to include whether a fire alarm or smoke detector were set off as well as which exit was used during the fire drill. After each unannounced fire drill the Quality Assurance, facility director, team will review the log to make sure it was completed in its entirety. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drills from December 2022 to June 2023, the facility failed to document whether alternate exit routes were used during fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has updated the current fire drill record to include which exit was used during the fire drill and whether alternate exit routes were used. After each unannounced fire drill the Quality Assurance, facility director, team will review the log to make sure it was completed in its entirety. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drills from December 2022 to June 2023, the facility failed to document whether a fire alarm or smoke detector was set off during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has updated the current fire drill record to include whether a fire alarm or smoke detector were set off. After each unannounced fire drill the Quality Assurance, facility director, team will review the log to make sure it was completed in its entirety. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients they had been notified that the project may not discriminate in the provision of services on the basis of color or marital status in fourteen of fourteen records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has updated the current client record and client handbook to include the written acknowledgement by clients to be notified that the project may not discriminate in the provision of services on the basis of color or marital status. The facility director is responsible for ensuring the correction action is implemented. Each client record will be monitored by the Clinical Supervisor, to ensure it is completed in its entirety. The Clinical Supervisor will complete monthly audits on all client records to ensure this deficiency does not recur. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients they had been notified that clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in fourteen of fourteen records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has updated the current client record and client handbook written acknowledgement for clients to be notified that clients have the right to inspect their own records. The facility director is responsible for ensuring the correction action is implemented. Each client record will be monitored by the Clinical Supervisor, to ensure it is completed in its entirety. The Clinical Supervisor will complete monthly audits on all client records to ensure this deficiency does not recur. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they have the right to appeal a decision limiting access to their records to the director in fourteen of fourteen records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has updated the current client record and client handbook written acknowledgement for clients to be notified that clients have the right to appeal a decision limiting access to their records to the director. The facility director is responsible for ensuring the correction action is implemented. Each client record will be monitored by the Clinical Supervisor to ensure it is completed in its entirety. The Clinical Supervisor will complete monthly audits on all client records to ensure this deficiency does not recur. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify one applicable client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice should include the reason for termination.
Client #7 was admitted on December 12, 2022 and discharged on February 21, 2023. There was no documentation in the record the client was notified in writing of the decision to involuntarily terminate the client ' s treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director notified the client verbally and in writing, of the decision to involuntarily terminate the client's treatment at the project. The notice included the reason for termination, and this is completed for all clients and documented in the client's record. The Clinical Supervisor will be responsible for ensuring the deficiency does not recur. The facility director is responsible to ensure the corrective action is implemented. The Clinical Supervisor will monitor discharge report and will notify each client in writing when terminating treatment and reason for termination and document in client's record. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to include the prompt review and identification of the causes directly or indirectly responsible for the unusual incident in the procedures for the following unusual incidents:
assault or sexual assault by staff or a client.
or use of illicit drugs on the premises.
disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
burglary, break-in or similar incident at the facility.
at the facility requiring the presence of police, fire or ambulance personnel.
or structural damage to the facility.
of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will correct the policy by including, prompt review and identification of the causes directly or indirectly responsible for the unusual incident in the procedures for the following unusual incidents:
assault or sexual assault by staff or a client or use of illicit drugs on the premises.
disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
burglary, break-in or similar incident at the facility.
at the facility requiring the presence of police, fire or ambulance personnel.
or structural damage to the facility.
of a contagious disease requiring Centers for Disease Control (CDC) notification.
The facility director will educate staff on the update by reviewing the policy and staff will acknowledge review and being educated by signing off on the policy. The facility director will monitor the policy and ensure the policy is being followed. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to include the implementation of a timely and appropriate corrective action plan, when indicated in the procedures for the following unusual incidents:
or use of illicit drugs on the premises.
disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
burglary, break-in or similar incident at the facility.
at the facility requiring the presence of police, fire or ambulance personnel.
or structural damage to the facility.
of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will correct the policy by including, a timely and appropriate corrective action plan, when indicated in the procedures for the following unusual incidents:
or use of illicit drugs on the premises.
disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
burglary, break-in or similar incident at the facility.
at the facility requiring the presence of police, fire or ambulance personnel.
or structural damage to the facility.
of a contagious disease requiring Centers for Disease Control (CDC) notification.
The facility director will educate staff on the update by reviewing the policy and staff will acknowledge review and being educated by signing off on the policy. The facility director will monitor the policy and ensure the policy is being followed. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to include the ongoing monitoring of the corrective action plan in the procedures for the following unusual incidents:
or use of illicit drugs on the premises.
disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
burglary, break-in or similar incident at the facility.
at the facility requiring the presence of police, fire or ambulance personnel.
or structural damage to the facility.
of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will include the ongoing monitoring of the corrective action plan in the procedures for the following unusual incidents:
or use of illicit drugs on the premises.
disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
burglary, break-in or similar incident at the facility.
at the facility requiring the presence of police, fire or ambulance personnel.
or structural damage to the facility.
of a contagious disease requiring Centers for Disease Control (CDC) notification.
The facility director will educate staff on the update by reviewing the policy and staff will acknowledge review and being educated by signing off on the policy. The facility director will monitor the policy and ensure the policy is being followed.
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to develop individual treatment and rehabilitation plans with clients that included the type of treatment and rehabilitation service in seven out of seven records reviewed.
Individual treatment and rehabilitation plans for each client identified a frequency along with each goal, however there was no documentation of the type of rehabilitation service that would be utilized to work on the goal.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor developed individual treatment and rehabilitation plans for all clients that included the type of treatment and rehabilitation service.
Individual treatment and rehabilitation plans were included for each client identified a frequency along with each goal. The Clinical Supervisor provided clinical supervision to educate the staff on ensuring the information is included in the client treatment and rehabilitation plans. The Clinical Supervisor will monitor this by conducting monthly chart audits and reviewing treatment plans in weekly supervision meetings to ensure this deficiency does not recur. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to develop individual treatment and rehabilitation plans with clients that included the type of treatment and rehabilitation service in seven out of seven records reviewed.
Individual treatment and rehabilitation plans for each client identified a frequency along with each goal, however there was no documentation of the type of rehabilitation service that would be utilized to work on the goal.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor developed individual treatment and rehabilitation plans for all clients that included the type of treatment and rehabilitation service.
Individual treatment and rehabilitation plans were included for each client identified a frequency along with each goal. The Clinical Supervisor provided clinical supervision to educate the staff on ensuring the information is included in the client treatment and rehabilitation plans. The Clinical Supervisor will monitor this by conducting monthly chart audits and reviewing treatment plans in weekly supervision meetings to ensure this deficiency does not recur. |