INITIAL COMMENTS
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General Comment
This report is a result of a renewal on-site licensure inspection conducted on 04/11/2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, XTRT6701 Easy Does It 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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§ 717.18(c)(3) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on a review of staff records, the recovery house failed to complete HIV/AIDS, tuberculosis, STD training using a department approved curriculum within 90 days of hire.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Deficiency 0192 relates to training requirements for staff and volunteers (Section 717.18(c)(3)) and concerns one instance where an employee's records did not demonstrate completion of "HIV/AIDS, tuberculosis, STD training using a department approved curriculum within 90 days of hire." The staff member in question completed a department approved Basic HIV training in November 2022 (within 90 days of hire) but was unable to secure a certificate of completion from the department. The staff member has requested department staff to provide a certificate of completion and one is expected soon, before 5/31/23. Concerning the second training of "tuberculosis, STD training," the employee in question is scheduled to receive a department approved training being offered in June 2023.
The recovery house has policy in place that satisfies the requirements of the regulation; this is an issue of implementation and supervision. The House Manager for the licensed recovery house (EDI's Director of Operations) is responsible for achieving and maintaining compliance with the training requirements for the employee in question, as well as all additional new volunteers and employees working at the recovery house. The House Manager has solidified a process for supervising and tracking completion of all training required by the department to ensure that this deficiency does not occur again. In the case of new volunteers and staff, all training requirements will be completed within 90 days of working at the recovery house. The timeframe for compliance with this regulatory requirement is May 10, 2023.
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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
Deficiency 0310 relates to timely notification to family or emergency contact (Section 717.27) and concerns one instance when a resident did not return to the recovery house as expected (AWOL), but "the recovery house failed to make at least one attempt to notify the resident's emergency contact ... [within] 12 hours...." In this instance, the discharge summary and note in the resident's record (chart) did not document the recovery house's attempts to notify the family or emergency contact.
The recovery house has policy in place that satisfies the requirements of the regulation; this is an issue of implementation and supervision. The House Manager for the licensed recovery house (EDI's Director of Operations) is responsible for achieving and maintaining compliance with the requirement. The House Manager will review this policy with all staff through individual and group supervision. In all future instances when emergency notification is required, the House Manager will ensure that the recovery specialist who has worked directly with the resident will attempt the emergency contact and document the resident's file with a note. The timeframe for compliance with this regulatory requirement is May 10, 2023.
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