INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11-12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pa Organization For Women in Early Recovery-Pittsburgh 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 and a plan of correction is due on February 7, 2010.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a discussion with the Facility Director the facility failed to present to the Department licensing representative at the time of the project's site visit, the plan documenting the qualifications and training of staff.
The findings include:
A discussion with the Facility Director took place on January 11, 2010 at approximately 10:15 AM regarding the completion of the plan documenting staff qualifications and training. The completed plan was required at the start of the site visit, January 11, 2010. The Facility Director did not complete the plan prior to the start of the site visit. Although she had read the letter sent to the facility indicating the plan was available online for printing she had set it aside and did not complete the plan. The Facility Director did not give the completed plan to the licensing representative until the last day of the site visit, January 14, 2010, which made it difficult for the licensing representative to complete the verification of staffing qualifications and training information.
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Plan of Correction
Not having the Staffing Plan prepared by the day of the visit was an oversight. While the Plan was completeted before the end of the visit, it will be prepared in advance of the next on-site visit. In the future,POWER's Associate & Clinical Director will notify the appropriate staff and direct the Executive Assistant to begin preparing the Sraffing Plan. The Plan will be prepared and ready for the Associate & Clinical Director's review and approval by the day preceding the scheduled on-site visit. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to comply with facility policy and procedure which requires that the preliminary treatment plan be documented within 10 days of the date of admission. The preliminary treatment and rehabilitation plan was not documented in two of five client records.
The findings include:
Five client records were reviewed on January 12 through January 13, 2010. A discussion with the Clinical Supervisor occurred on January 13, 2010 and it was determined that two out of five client records revived did not contain preliminary treatment plans. Preliminary treatment and rehabilitation plans were required in five client records.
The facility failed to document preliminary treatment and rehabilitation plans in client records #2 and 4.
Client # 2 was admitted on 5/28/09. There was no documentation of the preliminary treatment plan as of January 13, 2010.
Client # 4 was admitted on 6/6/09. There was no documentation of the preliminary treatment plan as of January 13, 2010.
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Plan of Correction
On January 20, the Associate & Clinical Director addressed this finding with the Treatment Team at POWER's Halfway House Program. The Associate & Clinical Director also assressed the requirement to complete an initial Treatment Plan within ten days of admission with the specific Terapist/Counselor who responsible, and her supervisor. The Supervisor will continue to monitor compliance based on the organization's Quality Assurance Plan. |