INITIAL COMMENTS
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This report is a result of an off-site telehealth-only licensure renewal inspection conducted on July 29, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the off-site inspection, Women's Institute For Family Health 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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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
The electronic health record system used by the facility has a client portal access. This allows clients to maintain an account on the facility ' s client portal, and an account is required to view all shared documents, to complete paperwork, to manage appointments, and to join telehealth sessions. The facility allows clients to sign up by sending a welcome email during the admissions process.
At the time of the inspection, the facility was not using their telehealth only recordkeeping system that allowed for efficient retrieval of data. There was one client admitted to the program since the facility received a telehealth only license from the Department. After discussions with facility staff, the facility did not give the admitted client access to the client portal in order to create an account to utilize all of the telehealth services available to them.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will assure that all clients have access to the client portal in the facility's Electronic Health Record system and that all client's admitted to the facility create an account, utilize, complete and submit all documents via the client portal. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in two of five applicable client records reviewed.
As indicated in facility's policy and procedure manual, the comprehensive (individual) treatment plan will be completed within four weeks of admission date.
Client #6 was admitted on February 19, 2026 and was discharged on March 26, 2026. The individual treatment and rehabilitation plan was due to be completed no later than March 21, 2026; however, there was no documentation indicating an individual treatment plan was developed prior to discharge.
Client #7 was admitted on February 17, 2026 and was discharged on March 26, 2026. The individual treatment and rehabilitation plan was due to be completed no later than March 19, 2026; however, there was no documentation indicating an individual treatment plan was developed prior to discharge.
This is a repeat citation from the July 6, 2023, July 11, 2024, and July 21, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will retain a clinical supervisor to review all client records on a weekly basis to assure that all records contain clinical documentation as per DDAP and WIFH standard operating procedures to avoid any future reoccurrence of this deficiency |
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 #2 was admitted on January 7, 2026 and was discharged on March 15, 2026. The individual treatment and rehabilitation plan was completed on February 5, 2026; however, the plan did not include documentation of both the type and frequency of treatment and rehabilitation services the client was to receive.
This is a repeat citation from the July 21, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will retain a clinical supervisor to review client records on a weekly basis to assure that all client records contain documentation as per DDAP and WIFH standard operating procedures to avoid future reoccurrence of this deficiency |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to develop individual treatment and rehabilitation plans with the client was submitted and approved by the Department for the July 6, 2023, July 11,2 024, and July 21, 2025, annual licensing inspections. Failing to develop individual treatment and rehabilitation plans with the client was again found to be a deficiency in the July 29, 2026, annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will retain a clinical supervisor to review client records on a weekly basis to assure that all records contain documents as per DDAP and WIFH standard operating procedures to avoid a reoccurrence of these deficiencies |