INITIAL COMMENTS
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This report is a result of an on-site Renewal licensure inspection conducted on March 15 , 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection OFM26701 YMCA of Reading and Berks County Camp Joy 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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§ 717.31(c)(3) 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:
(3) Fire, storm, flood or other occurrence that results in the closure of the drug and alcohol recovery house or the relocation of residents for more than one day.
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Observations
Based on a review of resident records the recovery house failed to report a unusual incident to the Department within 3 days that was a result of a fire, storm, flood or other occurrence that results in the closure of the drug and alcohol recovery house or the relocation of residents for more than one day.
Findings:
The recovery house failed to file a unusual incident report with the Department within 3 business days that resulted in relocation of residents for more then 1 day due to storm damage to the property of the recovery house.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
Implementation of Change is as follows":
The Unusual Incident has been filed in the DDAP system as of 03/25/24 at 12:35 pm.
Moving forward any incidents that result in the need to move clients out of the facility or are under the guidelines of Unusual Incidents will be reported in the DDAP system within 3 days of the Unusual Incident.
This will be monitored by Gena Pina Garcia on a weekly basis to insure there will not be a reoccurrence of this situation. |