INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 07, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 136032 Self Help Movement 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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§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of staff records the recovery house failed to have a mechanism to collect feedback on completed training in all staff records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Human Resources Director will meet with and train staff to monitor the RELIAS program to ensure that all staff complete a mechanism for all completed trainings. |
§ 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 have staff complete the HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum within the first 90 days of hire in 1 of 3 staff records. Staff # 102 was hired on January 01, 2009, Staff member failed to complete Department approved curriculum within the first 90days. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Human Resources Director will meet with and train staff to monitor and ensure that the training plan for all staff and volunteers contain the HIV/ADS and TB/STD and that the training is completed within 90 days of becoming and employee or volunteer. |
§ 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.
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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 1 of 3 staff records.Staff # 103 was hired on September 19, 2022, Staff member failed to complete Department approved curriculum within the first 90days. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Human Resources Director will meet with and monitor staff to ensure that the training plan for all staff and volunteers contain the fire prevention & emergency preparedness, including use of a fire extinguisher training and that the training is completed within 90 days of becoming and employee or volunteer.
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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
Based on a review of resident records, the recovery house failed to obtain written acknowledgement by residents stating they have received notice of their rights in all resident records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Recovery House Supervisor will meet with, monitor and train staff to ensure that all residents receive written acknowledgment of their rights as soon as they enter the program. |
§ 717.22(b)(1) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
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Observations
Based on a review of resident records, the recovery house failed to complete the disclosure criteria for beginning and ending residency within 24 hours of resident arrival in all resident records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Recovery House Supervisor will meet with, monitor, and train staff to ensure that all residents sign an acknowledgment that they received the facility criteria for beginning and ending residency within 24 hours of arrival to the facility. |
§ 717.22(b)(2)(i) 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:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(i) Drug and alcohol recovery house rules, including a method to record residents' expected return time to the drug and alcohol recovery house.
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Observations
Based on a review of resident records, the recovery house failed to have residents sign all orientation documentation within 24 hours of arrival in all resident records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Recovery House Supervisor will meet with, monitor and train staff to ensure that all residents sign the facility orientation documentation within 24 hours of arrival to the facility. |
? 717.22(b) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
(2) Resident orientation to the drug and alcohol recovery house which must include all of the following:
(i) Drug and alcohol recovery house rules, including a method to record residents ' expected return time to the drug and alcohol recovery house.
(ii) Fee schedule including any lease agreement.
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
(iv) Financial policies and procedures.
(v) The location of posted emergency procedures and contact information for the house manager and the Department.
(vi) Medication control and self-administration policies.
(3) Basic personal data including:
(i) Name.
(ii) Birth date.
(iii) Demographic information.
(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.
(v) Drug and alcohol history.
(vi) Medical contact information.
(vii) Emergency contact.
(4) Consent to residency.
(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.
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Observations
Based on a review of resident records, the recovery house failed to document all basic personal data within 24 hours of arrival in all resident records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Recovery House Supervisor will meet with, monitor and train staff to ensure that all personal data is recorded in the resident record within 24 hours of arrival to the facility. |
§ 717.22(b)(4) 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:
(4) Consent to residency.
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Observations
Based on a review of resident records, the recovery house failed to have resident sign consent to residency form within 24 hours of arrival in all resident records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Recovery House Supervisor will meet with, monitor and train staff to ensure that residents sign a consent to residency form within 24 hours of arrival to the facility. |
§ 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.
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Observations
Based on a review of resident records, the recovery house failed to disclose the policies and procedures within 24 hours of arrival for 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.
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Plan of Correction
The Recovery House Supervisor will meet with, monitor and train staff to ensure that the client signs off that the facility's policies and procedures for the notification of a resident's emergency contact within is disclosed 24 hours of arrival to the facility. |
§ 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
The Recovery House Supervisor will meet with, monitor and train staff to ensure that the client signs off that the facility's policies and procedures for the notification of a resident's emergency contact within is disclosed 24 hours of arrival to the facility. |