INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on March 5, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection O3QR6701 Ready, Willing, and Able Philadelphia, Urban Affairs Coalition was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
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Plan of Correction
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§ 717.27 LICENSURE Notification to family or emergency contact
§ 717.27. Notification to family member or emergency contact.
(a) The licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent. The resident may revoke consent to provide notice to the emergency contact.
(b) The licensee shall make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. This subsection shall not apply if the licensee knows or has reason to know of allegations of domestic abuse on the resident by the emergency contact.
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Observations
Based on a review of resident records, the recovery house failed to make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected.Findings:In 5 out of 7 resident discharge records the recovery house failed to notify the emergency contact within 12 hours of resident departure.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On March 11, 2024, House Manager (Executive Director) developed and implemented plan to notify the emergency contact, which may be a family member, which the client consented to in writing at intake. Ready, Willing & Able Philadelphia's "AWOL" status begins at midnight on any night a client does not return as planned. By noon the following day, staff will call the emergency number to inform the contact that the client's whereabouts are unknown. The plan includes responsibilities for which staff positions will call emergency contacts on weekends and holidays if necessary. Notation of attempt to call emergency contact will not be included on SCA discharge forms for clients who self-discharge and/or remain AWOL to the point of being discharged.
House Manager (Executive Director) has overall responsibility to assure this policy is followed.
Recovery Program Director (new hire will start work April 1, 2024) will oversee Case Managers and provide direct oversight of this policy.
Case Managers will call emergency contacts during weekdays.
On weekends and holidays, a rotating responsibility which will include Case Managers, Recovery Program Director, and House Manager (Executive Director) will make these calls.
Case Managers will note on SCA discharge form: staff person who called emergency contact, date and time of call, and the result of that call.
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§ 717.31(c)(4) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(4) An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of resident records, the recovery house failed to file a written unusual incident report with the Department within three business days following an unusual incident involving an event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On March 12, 2024, House Manager (Executive Director) input details of the missing Unusual Incident report into the DDAP Electronic Reporting System.
House Manager (Executive Director) will be responsible for inputting all future Unusual Incidents into DDAP ERS within three business days. In the House Manager's (Executive Director) absence, the Recovery Program Director (new hire will start April 1, 2024) will input Unusual Incidents into DDAP ERS.
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