D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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ANGEL'S LIGHT HALF WAY HOUSE, LLC
211 DEPOT STREET
YOUNGWOOD, PA 15697

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Survey conducted on 01/09/2025

INITIAL COMMENTS
This report is a result of an on-site follow-up inspection and complaint investigation conducted on January 9, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure and Program Operations. Based on the findings of the on-site inspection, Angels Light Half Way House, LLC. 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
705.2 (2) LICENSURE Building exterior and grounds. 705.2. Building exterior and grounds. The residential facility shall: (2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
Observations Based on a physical plant inspection, the facilty failed to maintain the grounds of the facility clean, safe, sanitary and in good repair at all times. A physical plant inspection was conducted on January 9, 2025. At the time of the inspection, the facility basement was found to have multiple refridgerator/freezer combo units that were not plugged in. One contained spoiled garlic bread. The other contained spoiled meat that smelled rancid. This finding was reviewed with the facility during the licensing process.	Plan of Correction The refrigerator/freezer combo located in the storage of the basement is not utilized for any client-related food storage. The refrigerator/freezer combo that was found to have spoiled food inside of it was cleaned and sanitized appropriately on 1/10/2025 by the lead tech who failed to inspect the refrigerator/freezer before removing it to the basement for storage purposes. The lead tech will ensure inspection of all items that will be stored in the basement not being utilized by the facility and report access needed to store items in the basement to the director. To monitor for compliance the director will complete random walkthroughs of the basement to ensure all approved items were stored in the basement storage area. If the lead tech does not report appropriately, the staff member will be written up as a direct result of not consulting appropriately.
709.32 (c) (4) (i) - (ii) LICENSURE Medication control § 709.32. Medication control. (4) Methods for control and accountability of drugs, including, but not limited to: (i) Who is authorized to remove drug. (ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
Observations Based on a review of client records, the facility failed to provide documentation of a complete medication administration record (MAR) in seven of ten applicable records. Client #2 was admitted on April 25, 2024 and discharged on September 20, 2024. A medication was listed on the MAR for " 100 units. " The MAR documented that the medication was to be given at 8:00am, 12:00pm, 4:00pm, and 9:00pm daily. There was no documentation of when this medication started. There was no documentation that this medication was given on April 25, 2024 at 12:00pm, April 26, 2024 at 12:00pm, April 27, 2024 at 9:00pm, and April 29, 2024 at 4:00pm. A medication was to be given " one tablet three times daily. " The MAR documented that the medication was to be given at 8:00am, 12:00pm, and 4:00pm daily. There was no documentation of when this medication started. There was no documentation that this medication was given on May 24, 2024 at 4:00pm, and May 27, 2024 at 4:00pm. A medication was listed on the MAR for " 100 units. " The MAR documented that the medication was to be given at 8:00am daily. There was no documentation of when this medication started. There was no documentation that this medication was given on June 28, 2024, August 5-31, 2024, September 2-4, 2024, and September 6-19, 2024. A medication was listed on the MAR for " 300 units. " The MAR documented that the medication was to be given at 8:00am daily. There was no documentation of when this medication started. There was no documentation that this medication was given on June 24, 2024, June 26, 2024, and June 28, 2024. A medication was listed on the MAR for " 300 units. " The MAR documented that the medication was to be given at 8:00am daily. There was no documentation of when this medication started. There was no documentation that this medication was given on September 2-19, 2024. Client #3 was admitted July 8, 2024 and discharged on December 27, 2024. There were no documented MARs for July 2024 and November 2024. A medication was listed on the MAR was to be given " one tab twice daily. " The MAR documented that the medication was to be given at 8:00am and 9:00pm daily. There was no documentation of when this medication started. There was no documentation that this medication was given on August 16, 2024 at 8:00am, August 20-23, 2024 at 8:00am, and August 26-31, 2024 at 8:00am. A medication was listed on the MAR to be given "one tablet twice daily." There was no documentation of when this medication started. The MAR did not document when the medication was to be taken. There was no documentation of this medication given on October 1-31, 2024. Starting on December 1, 2024, a medication was to be given "take one cap three times daily " The MAR documented that the medication was given at 8:00am, 4:00pm, and 9:00pm. There was no documentation of this medication given on December 5, 2024 at 4:00pm, December 7, 2024 at 4:00pm, December 8, 2024 at 8:00am and 4:00pm, and December 15, 2024 at 4:00pm. Starting on December 1, 2024, a medication was to be given "take one tablet twice daily." The MAR only documented that the medication was given at 9:00pm. There was no documentation of the second dose of this medication given on December 1-10, 2024, December 12-26, 2024. There was also a second dose given on December 11, 2024, but there was no documentation of the time. A medication was listed on the MAR to be given "take one tab three times daily." There was no documentation of when this medication started. MAR only documented that the medication was given at 8:00am. There was no documentation of the second and third doses given December 1-27, 2024. A medication was listed on the MAR to be given "take one tab daily. " There was no documentation of when this medication started. The medication was marked as " discontinued, " but there was no date indicated. Client #5 was admitted on September 27, 2024 and discharged on November 12, 2024. A medication was listed on the MAR to be given "take one tablet daily " There was no documentation of when this medication started. The MAR did not document when the medication was to be taken. There was no documentation of this medication given on November 1-12, 2024. Client #7 was admitted on June 10, 2024 and discharged on November 21, 2024. Starting on August 20, 2024, a medication was to be given "take one cap four times daily. " The MAR documented that the medication was to be given at 8:00am, 12:00pm, 4:00pm, and 9:00pm. There was no documentation of this medication given on August 21, 2024 at 4:00pm, August 22, 2024 at 4:00pm, August 23, 2024 at 12:00pm and 4:00pm, August 24, 2024 at 4:00pm, August 25, 2024 at 12:00pm and 4:00pm, and August 26-31, 2024 at 8:00am, 12:00pm, and 4:00pm. Starting on September 15, 2024, a medication was to be given "take one cap four times daily until gone. " The MAR documented that the medication was to be given at 8:00am, 12:00pm, 4:00pm, and 9:00pm. There was no documentation of this medication given on September 15, 2024 at 8:00am, 12:00pm, and 4:00pm, September 16-19, 2024 at 8:00am, 12:00pm, 4:00pm, and 9:00pm, September 21, 2024 at 12:00pm and 4:00pm, September 22-24, 2024 at 8:00am, 12:00pm, and 4:00pm, September 25-26, 2024 at 8:00am, 12:00pm, 4:00pm and 9:00pm, and September 27-30, 2024 at 8:00am, 12:00pm, and 4:00pm. Client #8 was admitted August 16, 2024 and was active at the time of the inspection. Starting on January 1, 2025, a medication was to be given " 1 time daily. " There was no documentation that the client received any of the medication in the month of January 2025. There was a note stating " D/C got shot " however, the date of the shot is not documented. Starting on January 2, 2025, a medication was to be given " as directed on package " . There was no documentation that this medication was given to the client for the month of January 2025. The MAR did not include the instructions directed on the package. There was no MAR documented for the month of August 2024 for client #8. Client #9 was admitted August 2, 2024 and was active at the time of the inspection. A medication was listed on the MAR to be given "1 tab in the AM. " There was no documentation of when this medication started. The medication was not documented as being given September 13-18, 2024. Starting on January 1, 2025, a medication was to be given " 1 tab daily for 10 days. " There was no documentation that the client received any of the medication in the month of January 2025. There was a note stating " D/C " however, the date the medication was discontinued was not documented. There was no MAR documented for the month of August 2024 for client #9. Client #10 was admitted December 27, 2024 and was active at the time of the inspection. Starting on December 1, 2024, a medication was to be given " 1 tab at bedtime. " There was no documentation this medication given on December 29 & 30, 2024. A line was drawn through December 1 - 26, 2024. It was reported verbally that the start date of December 1, 2024 was an error. Starting on December 1, 2024, a medication was to be given " 1 time daily " . There was no documentation that the client received this medication at any time in December 2024. This finding was reviewed with the facility during the licensing process. This is a repeat citation from the April 24, 2024 and January 10, 2024 licensing inspections.	Plan of Correction The Director will create and train all tech/clinical staff via PowerPoint to serve as the staff training method for the medication training to ensure appropriate education. Tech/clinical staff who oversee the observation medication pass will be trained to ensure that staff are educated on appropriately recording the following: medication name, dosage, instruction of the medication, time of medication, initialing the MAR, the start/stop date, the month and year to the MAR, identifying PRN medication, discontinuation of medication, starting of new prescribed medication and/or dosage and/or times per day change, medication no shows, medication refusals, times of medication, documentation of OTC medications given. The Director will create training during February of 2025 and have tech/clinical staff trained individually on or before 2/28/2025. The director will oversee the medication process and continue to monitor this process daily while in the facility. The director will also complete MAR sheet audits monthly and upon client discharges to monitor for any areas of reeducation needed with particular staff observing medication pass.
709.53(a)(11) LICENSURE Follow-up information 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: (11) Follow-up information.
Observations Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in seven of seven applicable records. The policy and procedure manual indicates follow-up contact must be made within five days of discharge. Client #1 was admitted on May 28, 2024 and discharged on May 31, 2024. There was no documentation of follow-up being completed. Client #2 was admitted on April 25, 2024 and discharged on September 20, 2024. There was no documentation of follow-up being completed. Client #3 was admitted July 8, 2024 and discharged on December 27, 2024. There was no documentation of follow-up being completed. Client #4 was admitted on August 12, 2024 and discharged on August 15, 2024. There was no documentation of follow-up being completed. Client #5 was admitted on September 27, 2024 and discharged on November 12, 2024. There was no documentation of follow-up being completed. Client #6 was admitted on October 7, 2024 and discharged on December 29, 2024. There was no documentation of follow-up being completed. Client #7 was admitted on June 10, 2024 and discharged on November 21, 2024. There was no documentation of follow-up being completed. This finding was reviewed with the facility during the licensing process. This is a repeat citation from the April 24, 2024 annual licensing inspection.	Plan of Correction The director has reviewed and provided reeducation to new clinical staff with the policy regarding client follow-up. An electronic follow-up form was created electronically and added to the client EMR on 12/31/2024 for completion of follow-up calls. The Director will complete chart audits upon discharge starting 2/1/2025 and monitor the follow-up call process for completion within the required policy timeframe of 5 days within discharge.