INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on July 14, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, LZUK6701, Depaul House was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing. 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 have residents sign notification to family member or emergency contact form in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
For the following plan of action the Associate Director is responsible for ensuring the corrective action (s) is implemented. All new residents upon entry will fill out updated client forms that include emergency contact procedure, the right to revoke emergency contact. Implementation of new policy for new residents starts immediately upon entry to Depaul House. Depaul House will have all existing clients and new clients in compliance by August 15th 2023. Employees will go over the new forms with existing clients and have them signed by the 15th of August. The employees shall have new clients sign the new forms with the existing intake packets upon entry as of 7/14/2023
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