INITIAL COMMENTS
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This report is a result of a renewal on-site licensure inspection conducted on March 28th, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 800P6701 East End Cooperative Ministry was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
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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 (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. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
1. As part of our intake process, each resident is required to sign and initial the emergency contact form. The House Manager or Case Manager will reach out by phone to the emergency contact upon NC/NS, and this call will be made within 12 hrs. The housing manager or case manager will document the outcome of the call made to the emergency contact in Salesforce as a note, and a copy will be placed in the resident's paper chart.
This plan of correction has been implemented on 4/17/2023.
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