INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 07, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, MM006701 Empowerworks 256 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.
|
Plan of Correction
|
§ 717.22(b)(3)(iv) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(3) Basic personal data including:
(iv) Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker, and other medical conditions that the resident chooses to have in the house record.
|
Observations
Based on a review of resident records, the recovery house failed to document all required basic personal data such as medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker, and other medical conditions that the resident chooses to have in the house record within 24 hours of arrival in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
COMPLETED: The House Manager will ensure that all resident files have been updated with the resident's medical information. Files will be reviewed semi-annually. This has been added to the application which will be completed upon the new resident's admission but no later than 24 hours upon arrival. |
§ 717.22(b)(5) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
|
Observations
Based on a review of resident records, the recovery house failed to have a signed notification of emergency disclosure form signed within 24 hours of arrival which identifies situations when recovery house staff may notify the resident ' s emergency contact in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
COMPLETED: The House Manager has updated the emergency disclosure form and are in client's charts. This disclosure form informs the resident when recovery house staff may notify the resident's emergency contact. The House Manager will review the resident files semi-annually.
|
§ 717.30(c)(1)(v) LICENSURE Safety and emergency procedures - Detectors
§ 717.30. Safety and emergency procedures.
(c) Smoke and carbon monoxide detectors.
(1) The licensee shall:
(v) Inspect, test and document that all smoke detectors and carbon monoxide detectors are functional monthly.
|
Observations
Based on the physical plant inspection, the recovery house failed to inspect, test and document that all smoke detectors and carbon monoxide detectors are functional monthly.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
COMPLETED: The House Manager has ensured the all smoke and carbon monoxide detectors have been checked and all are fully functional. A monthly check will be completed by the House Manager and will be documented.
|