INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on February 20, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection PE7Y6701 It ' s the Keys to Life LLC 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 residents 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 3 out of 5 resident files the recovery house failed to notify the emergency contact within 12 hours of residents departure.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
An event the resident maybe discharge and/or decides to leave the Recovery House. The house manager will notify the emergency contract within 12 hours after leaving the premises.
The house manager will continue to monitor the call will be made within 12 hours after departure. This correction has been an effective as of March 13, 2024. |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
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Observations
Based on a the physical plant inspection the recovery house failed to have fire extinguishers inspected and approved annually by the local fire department or fire extinguisher company.
Findings:
The inspection of fire extinguishers have not been completed annually.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Annual fire extinguishers inspections will be conducted yearly on or before March 13, of every year.
This correction has been an effective as of March 13, 2024, the fire extinguishers are up to date. |