INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on June 09, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, MM006701, Empowerworks 256 Recovery House was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing. 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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§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of staff records, the recovery house failed to have a complete staff record. The recovery house failed to have a mechanism to collect feedback on completed training in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
1. A training feedback form has been created for all staff to date and sign upon the completion of all trainings. These forms will be placed in the individual's staff file.
2. EmpowerWorks will be responsible for ensuring that all trainings taken by staff will have a signed feedback form for each training taken.
3. EmpowerWorks has created a training feedback form and it will be used for all completed training by staff.
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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 have resident sign notification to family member or emergency contact from in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
1. The Consent to Residency has been updated to include information about the notification to family member or emergency contact. This form will be signed and dated by the resident.
2. EmpowerWorks will be responsible for ensuring that the all resident folders includes the Consent to Residency, which outlines the notification to the resident's emergency contact/
3. EmpowerWorks has updated the Consent to Residency form for all EmpowerWorks houses.
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§ 717.30(b)(2) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(2) Maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
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Observations
Based on the physical plant inspection the house failed to have two unobstructed exits separated by a minimum distance of 15 feet within the bedroom space in the attic.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
EmpowerWorks plan of correction is to build a platform to safely exit the attic level to the ground.
The projected timeframe for this to completed is 8/21/23.
The house manager will check the path to the platform monthly to make sure that the it remains clear of all debris, snow, ice, etc. |