INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 6N9M6701 3837 Walnut St 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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§ 717.19(b) LICENSURE Resident Rights
§ 717.19. Resident rights.
(b) The licensee shall obtain written acknowledgement by residents that they have received notice of their rights.
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Observations
The licensee failed to obtain written acknowledgement by residents that they have received notice of their rights in 2 out of 8 records.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
All records for current residents have been uploaded to Sobriety Hub. The DDAP representative has been provided with credentials to access all records. The licensee's house superintendent has been directed to ensure all residents acknowledge in writing that they have been provided a notice of resident rights. This was done 12/30/24. Written acknowledgement is required by facility policy. The superintendent has been further directed to upload a residents application packet and signed resident packet to Sobriety Hub within 48 hours of the resident's arrival. This was done 12/30/24. Review of the resident's file will be verified Angela Noon, member BOD. |
§ 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.
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Observations
The license failed to ask and document 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.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
The House Superintendent has been directed, when completing the orientation of a new resident, to specifically request what information the resident desire to be included in their file. This was done 12/30/24. A prospective resident's medical conditions is a specific inquiry required by the licensee's policy at orientation. This information shall be added to the resident's file in Sobriety Hub within 48 hours of the resident's arrival. The Sobriety Hub submissions will be reviewed by Angela Noon, member, BOD for accuracy. |
§ 717.22(b)(3)(v) 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:
(v) Drug and alcohol history.
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Observations
The licensee failed to document the residents drug and alcohol history in all records reviewed.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
The licensee's resident orientation packet requests the drug and alcohol history of each new resident. The house superintendent has been directed to ensure this section of the packet is completed. This was done 12/30/24. Upon completion of the packet, the packet is to be uploaded into Sobriety Hub within 48 hours of the resident's arrival. The Sobriety Hub submissions will be reviewed by a Angela Noon, member, BOD for accuracy. Any current resident's fie lacking this information, is to be amended on or before 01/05/2025 |
§ 717.22(b)(3)(vi) 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:
(vi) Medical contact information.
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Observations
The licnesee failed to ask and document medical contact infomration.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
The licensee's resident orientation packet requests medical contact/emergency contact of each new resident. The house superintendent has been directed to ensure this section of the packet is completed. This was done 12/30/24. Upon completion of the packet, the packet is to be uploaded into Sobriety Hub within 48 hours of the resident's arrival. The Sobriety Hub submissions will be reviewed by Angela Noon, member, BOD for accuracy. Any current resident's fie lacking this information, is to be amended on or before 01/05/2025 |
§ 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
The licensee failed to have emergency contact information and documented call to the contact in 3 out of 8 records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
See responses to preceding POC's. By way of further response, the house superintendent has been directed to log in Sobriety Hub, all emergency contact calls made on behalf of a resident whether such call is made regarding a medical situation, failure of a resident to return to the licensed facility or in the event the resident has vacated the facility or been discharged. This was done 12/30/24.
The licensee's Critical Incident Form has been amended to require the logging of such calls. Angela Noon, member, BOD will ensure compliance. |