INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2024, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of three personnel records, the facility failed to ensure that one employee had a written individual training plan that was developed annually.
Employee # 2 was hired as the Clinical Supervisor on January 8, 2024 and was current in that position at the time of the inspection. Employee # 2 should have had an initial individual training plan developed within 30 days of the date of hire, however a written individual training plan was not developed until March 11, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 704.11(b)(1) The facility director will ensure that upon hire, all new employees assist their supervisor in the completion of a written individualized training plan for them that is directly related to their position and their skill level. Training plans have been completed with all current staff. This process is completed, and the program is back to compliance. In order to ensure this will not recur, a checklist has been made that will be followed for each new employee that includes training topics such as this and each new employee file will be examined one-week following their date of hire to identify any missed items. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of three personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.
Employee # 1 was hired as the Project and Facility Director on February 19, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until June 17, 2024.
Employee # 2 was hired as the Clinical Supervisor on January 8, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until June 17, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 705.28 (c) (4) the facility director will ensure that all new staff will complete "Fire Safety and Emergency Preparedness REL-PAC-0-FSEP"on the Relias training platform prior to beginning their first shift which includes detailed instructions on how to use a fire extinguisher. Current staff have completed this training. This process is completed, and the program is back to compliance. In order to ensure this will not recur, a checklist has been made that will be followed for each new employee that includes this specific training. Each new employee file will be examined one-week following their date of hire to identify any missed items and rectify any issues. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from August 2023 through May 2024, the facility failed to conduct unannounced fire drills during February, March, and April 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 705.28 (d) (1) the facility director will ensure that unannounced fire drills occur at least once a month. The dates of future drills have been planned out on random days and shifts on the facility directors' private calendar. This calendar will notify the director that it is time to run a new drill. This will ensure that the drills are being completed on time and in sufficient numbers. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of three personnel records, the facility failed to ensure that two applicable staff members were trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 1 was hired as the Project and Facility Director on February 19, 2024 and is current in that position. Employee # 1 began working shifts on February 19, 2024, but was not trained to perform assigned tasks during emergencies until June 17, 2024.
Employee # 2 was hired as the Clinical Supervisor on January 8, 2024 and is current in that position. Employee # 2 began working shifts on January 8, 2024, but was not trained to perform assigned tasks during emergencies until June 17, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 705.28 (d) (3) the facility director will ensure that all current and new staff will complete "Fire Safety and Emergency Preparedness REL-PAC-0-FSEP"on the Relias training platform prior to beginning their first shift which includes detailed instructions on how to oversee, conduct, and participate in evacuations, both planned and unplanned. Current employees have already completed this training. This training has been added to a checklist that will be completed as a part of the first week of all new hires. The training will be completed the first day, but the list will be checked one week after their start date to ensure this and other important milestones are met. |
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 August 2023 through May 2024 fire drill logs, the facility failed to include required information on the fire drill logs.
The May 2024 fire drill log was missing the time, length of time to evacuate, and the exit route.
The January 2024 fire drill log was missing the time, the exit route, and whether the fire alarm or smoke detector was operative.
The logs from November 2023 and August 2023 were missing whether the fire alarm or smoke detector was operative.
This is a repeat citation from the July 13, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As per 705.28 (d)(4) the facility director has re-written the fire\evacuation drill log to include a written account of 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 and enacted it use in facility practice. This new form has been enacted and the drills have been scheduled out on the director's calendar. The Clinical director will ensure that the new form is used moving forward. The forms will also be reviewed on the first of each month to ensure that the previous month's evacuation drill occurred. This was added to the director's calendar as well.
An exemption has been granted to the program to allow for use of a siren not connected to the building's system so it will not affect the numerous other companies occupying the building. The use of this alternative siren was added to the new fire\evacuation drill log. As a part of that exemption, documentation will be provided that the alarm system is checked and maintained by a professional and is in good working order. |
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 seven client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five records reviewed.
Client # 2 was admitted on May 6, 2024 and was discharged on May 28, 2024. The individual treatment and rehabilitation plan was completed on May 22, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on April 5, 2024 and was discharged on April 22, 2024. The individual treatment and rehabilitation plan was completed on April 8, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on January 25, 2024 and was discharged on February 5, 2024. The individual treatment and rehabilitation plan was completed on January 29, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on June 26, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 5, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on June 26, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 27, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
This is a repeat citation from the July 13, 2023 annual licensing renewal inspection.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As per 709.82(a)(2) the facility director and clinical supervisor will ensure that new staff are aware of the need for individual treatment plans to include the type and frequency of treatment and rehabilitation services prior to their first shift. Current staff have been retrained to include these details. This expectation will also continue to be identified during supervision sessions and team meetings.
Specifics regarding timeline compliance and specific service expectations has been added to the new hire checklist. This will be completed during the first week of every new hire and reviewed one week following hire to ensure all checklist items are completed. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide individual counseling sessions two times weekly for clients in the partial hospitalization activity in four of six client records reviewed.
Client # 1 was admitted on December 21, 2023 and was discharged on January 31, 2024. The record did not contain documentation of an individual counseling session for the treatment week of December 21, 2023 through December 27, 2023. Additionally, the record only contained documentation of one counseling session during the treatment week of January 25, 2024 through January 31, 2024.
Client # 2 was admitted on May 6, 2024 and was discharged on May 28, 2024. The record did not contain documentation of an individual counseling session for the treatment weeks of May 6, 2024 and May 13, 2024. Additionally, the record only contained documentation of one counseling session during the treatment week of May 20, 2024.
Client # 3 was admitted on January 17, 2024 and was transferred to a lower level of care on February 23, 2024. The record did not contain documentation of an individual counseling session for the treatment weeks of January 24, 2024 and February 14, 2024. Additionally, the record only contained documentation of one counseling session during the treatment week of February 7, 2024 through February 13, 2024.
Client # 6 was admitted on June 26, 2024 and was active at the time of the inspection. The record only contained documentation of one individual counseling session for the treatment week of June 26, 2024 through July 2, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 709.82(d)(1) the facility director and clinical supervisor will ensure that new and current staff are aware of the need for clients in partial hospitalization level of care to have 2, regularly scheduled individual sessions per week. New staff will be trained on this prior to their first shift and current staff have been retrained. This expectation will be identified and reiterated during individual staff supervision as well as team meetings. This process is completed, and the program is back to compliance. |
709.83(a)(11) LICENSURE Client records
709.83. 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.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of three applicable records reviewed.
Client # 1 was admitted on December 21, 2023 and was discharged on January 31, 2024. There was no documentation of follow-up information in the record.
Client # 2 was admitted on May 6, 2024 and was discharged on May 28, 2024. There was no documentation of follow-up information in the record.
Client # 4 was admitted on April 5, 2024 and was discharged on April 22, 2024. There was no documentation of follow-up information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 709.83(a)(11) facility director will ensure that clients who have been discharged from the facility receive a follow up call or email post discharge from the facility and that this will be documented in the client's chart. New staff will be trained to complete this task prior to their first shift and current staff have been retrained. This expectation will be identified and reiterated during individual staff supervision as well as team meetings. This process is completed, and the program is back to compliance.
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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 document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in one of three applicable records reviewed.
Client # 13 was transferred from a higher level of care on March 13, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 18, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
This is a repeat citation from the July 13, 2023 annual licensing renewal inspection.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As per 709.92(a)(2) the facility director and clinical supervisor will ensure that new and current staff are aware of the need for individual treatment plans to include the type and frequency of treatment and rehabilitation services. New staff will be trained on this prior to their first shift and current staff have already been retrained. This expectation will be identified and reiterated during individual staff supervision as well as team meetings. This process is completed, and the program is back to compliance. |
709.93(a)(5) LICENSURE Client records
709.93. 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed before the end of the clinical staff member ' s shift, in four of seven records reviewed.
Client # 10 was admitted on December 5, 2023 and was discharged on February 21, 2024. The record contained progress notes for individual sessions occurring on December 6, 2023 and December 20, 2023, that were not completed until December 15, 2023 and January 2, 2024, respectively.
Client # 11 was admitted on January 15, 2024 and was discharged on June 18, 2024. The record contained a progress note for an individual session occurring on April 23, 2024, that was not completed until June 21, 2024. Additionally, the record contained documentation of an individual session occurring on May 22, 2024, that was not completed as of the date of the inspection.
Client # 13 was admitted on March 13, 2024 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on April 25, 2024, that was not completed until June 21, 2024. Additionally, the record contained documentation of individual sessions occurring on May 6, 2024 and May 23, 2024, that were not completed as of the date of the inspection.
Client # 14 was admitted on March 22, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on March 27, 2024 and May 30, 2024, that were not completed until April 14, 2024 and June 11, 2024, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 709.93(a)(5) the facility director and clinical supervisor will ensure that new and current staff are aware of the need for individual progress notes throughout the client's time in treatment. New staff will be trained on this prior to their first shift and current staff have been retrained on this. This expectation will be identified and reiterated during individual staff supervision as well as team meetings. Policy has been changed so that there is a more manageable 24h timeframe for note completion. Both the clinical director and the clinical supervisor will audit charts monthly to ensure documentation is completed during these timelines. |
709.93(a)(11) LICENSURE Client records
709.93. 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.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of three applicable records reviewed.
Client # 8 was admitted on February 23, 2024 and was discharged on March 19, 2024. There was no documentation of follow-up information in the record.
Client # 9 was admitted on October 17, 2023 and was discharged on December 29, 2023. There was no documentation of follow-up information in the record.
Client # 10 was admitted on December 5, 2023 and was discharged on February 21, 2024. There was no documentation of follow-up information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 709.83(a)(11) facility director will ensure that clients who have been discharged from the facility receive a follow up call or email post discharge from the facility. New staff will be trained to complete this task prior to their first shift and current staff have been retrained. This expectation will be identified and reiterated during individual staff supervision as well as team meetings. This process is completed, and the program is back to compliance.
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