This report is a result of an on-site licensure renewal inspection conducted on January 6, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Foster Hill Wellness, 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:
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Plan of Correction
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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(iv) Outdated drugs are removed.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 physical plant inspection on January 6, 2026, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was a topical ointment stored with the oral medication in the medication cart.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the deficiency, the facility immediately removed the topical ointment from the medication cart and ensured that all drugs for external use were stored separately from oral and injectable medications in accordance with facility policy and applicable regulations.
Effective immediately, the Nursing Supervisor will ensure that all medication storage areas, including medication carts, are organized to maintain separation between (1) oral/injectable medications and (2) drugs for external use. Staff have been reminded that topical medications may not be stored in the same bin or area as oral medications at any time.
To ensure ongoing compliance, the Nursing Supervisor will implement weekly medication cart inspections for 60 days to confirm proper storage and separation of external-use medications from oral and injectable medications. Findings will be recorded on the medication storage inspection log and any non-compliance will be corrected immediately and addressed with the responsible staff member. After 60 days, inspections will return to the facility's standard quarterly medication storage inspection schedule, at minimum, as required.
Training will be held on or before 01/31/2026 with all nursing and medication-handling staff regarding medication storage requirements, proper separation of external-use medications, and inspection/documentation procedures. This training will be completed at time of hire and will occur yearly thereafter for all staff responsible for medication storage and handling.
Medication storage procedures and inspection findings will be reviewed during monthly performance-improvement meetings to ensure sustained compliance.
Completion Date: 01/31/2026 |