INITIAL COMMENTS
|
his report is a result of an on-site licensure renewal inspection conducted on December 22, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, CDXO6701 Joy in the Journey 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.
|
Plan of Correction
|
§ 717.18(c)(1) 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:
(1) Cardiopulmonary resuscitation (CPR) certification.
|
Observations
Based on a review of staff records, the recovery house failed to have staff complete the cardiopulmonary resuscitation (CPR) certification within the first 90 days of hire in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The recovery house manager convened a meeting with all staff members to review all new hire paperwork and update all essential orientation paperwork. All current staff paperwork has been updated as of 01/01/2023. Additionally, the recovery house manager has established a quarterly review process for all staff records to ensure the proper completion of all necessary documents. |
§ 717.18(c)(2) 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:
(2) First aid training, including training on overdose reversal medication.
|
Observations
Based on a review of staff records, the recovery house failed to have staff complete the first aid training, including training on overdose reversal medication certification within the first 90 days of hire in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The recovery house manager convened a meeting with all staff members to review all new hire paperwork and update all essential orientation paperwork. All current staff paperwork has been updated as of 01/01/2023. Additionally, the recovery house manager has established a quarterly review process for all staff records to ensure the proper completion of all necessary documents.
I have provided training information and resources that's available for staff to complete within the first 30- 90 days of hire. I will continue to update the information as needed. |
§ 717.18(c)(4) 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:
(4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
|
Observations
Based on a review of staff records, the recovery house failed to have staff complete the Fire prevention and emergency preparedness, including use of a fire extinguisher within the first 90 days of hire in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The recovery house manager convened a meeting with all staff members to review all new hire paperwork and update all essential orientation paperwork. All current staff paperwork has been updated as of 01/01/2023. Additionally, the recovery house manager has established a quarterly review process for all staff records to ensure the proper completion of all necessary documents. There will be a mandatory fire prevention training every 60 days to ensure that all new residents and staff is familiar with all the fire escapes and exits and time evacuate the resident in a timely manner. All fire prevention equipment is working and in place. |
§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
|
Observations
Based on a review of resident records, the recovery house failed to maintain an individual record for each resident in the recovery house.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Recovery House Manager convened a meeting with staff to receive and update all resident records. Recovery House Manager have met with all current residents and reviewed and updated all required documents. |
§ 717.22(b)(3)(vii) 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:
(vii) Emergency contact.
|
Observations
Based on a review of resident records, the recovery house failed to complete all basic personal data including emergency contact form within 24 hours of arrival in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Recovery House Manager convened a meeting with staff to receive and update all resident records. Recovery House Manager have met with all current residents and reviewed and updated all required documents.
|
§ 717.22(b)(5) 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:
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
|
Observations
Based on a review of resident records, the recovery house failed to disclose and have resident sign the notification of emergency form within 24 hours of arrival which identifies situations when recovery house staff may notify the resident ' s emergency contact in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Recovery House Manager convened a meeting with staff to receive and update all resident records on 01/01.24. Recovery House Manager have met with all current residents and reviewed and updated all required documents. Recovery House Manager was able to update the emergency contact form and have residents sign off and receive a copy. |