INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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
The facility failed to document fire drills at least once a month.
The fire drill logs were requested on January 30, 2020. The period reviewd was January 2019 through January 2020. There were no fire drills documented for the months of January, March, April and June 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drill Logs will be kept for at least one drill per month and also documented ALL times the fire alarm goes off regardless of whether it was a planned drill or not. The Program Admin Assistant has been re-trained as of 02/07/2020 on how to document fire drills properly. The Facility Director will insure that drills are occurring monthly and recorded properly on the Fire Drill Log by the Program Admin Assistant. |
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(iv) Outdated drugs are removed.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
The facility failed to document inspections of the medication storage areas.
The medication inspection logs were requested on January 30, 2020. There were no inspections of the medication storage area documented for the licensing period being reviewd, January 2019 through January 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medication Process has been revised and all staff have been properly trained on all parts of the process by 02/13/2020. The new process includes regular inspections of the medication storage area by both the shift supervisor and agency nurse. The inspection logs will be reviewed regularly by the Facility Director. |