INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 09, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 136033 Savage Sisters Recovery INC 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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§ 717.17(b)(4) LICENSURE Personnel Management
§ 717.17. Personnel management.
(b) The written policies and procedures must include:
(4) Orientation of new employees.
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Observations
Based on a review of staff records the recovery house failed to include a staff orientation in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Orientation was reviewed with staff and uploaded to a digital copy that staff has access to. Existing staff has access to their staff orientation file at anytime through Savage Sisters shared google drive. New staff are to be presented with the staff orientation within two business days of accepting their offer letter from Savage Sisters Recovery, and will have access to the file at anytime in Savage Sisters shared google drive. |
§ 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
Savage Sisters Executive Director is going to expand on staff orientation, staff policy and procedures by January 1st, 2024. Additionally, a google form has been created to collect feedback on completed training. The google form feedback questionnaire is to be sent to all employees participating in a training within 24 hours of the training. All records of staff training responses are to be kept and easily accessed in the shared Savage Sisters Google Drive in the staff Feedback folder. |
§ 717.18(b) LICENSURE Training
§ 717.18. Training.
(b) The licensee shall conduct and document an evaluation of the training plan annually.
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Observations
Based on a review of staff records the recovery house failed to conduct and document an annually training plan 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 recovery house will conduct and document an annual training plan in all staff records. This will be completed by 1/22/23. The annual training plan will be conducted by the Executive Director at least once annually by January 31st of each year. |
§ 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.
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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.
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Plan of Correction
The employee that holds the position that DDAP recognizes as House Manager will be CPR trained by 2/1/23, and all employees holding that position moving forward will have to be CPR trained within 60 days of being hired. CPR certifications must be accessible in Savage Sisters shared google drive in the certifications folder.
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§ 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.
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Observations
Based on a review of staff records, the recovery house failed to have staff complete the first aid training, within the first 90 days of hire in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Staff will be First Aid trained by 2/1/23. The employee that holds the position that DDAP recognizes as House Manager will be First Aid trained by 2/1/24, and all employees holding that position moving forward will have to be First Aid trained within 60 days of being hired. First Aid certifications must be accessible in Savage Sisters shared google drive in the certifications folder.
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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 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 all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Staff will complete the HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum by 2/1/24. The employee that holds the position that DDAP recognizes as House Manager will be HIV/AIDS trained by 2/1/24, and all employees holding that position moving forward will have to be HIV/AIDS trained within 60 days of being hired. HIV/AIDS certifications must be accessible in Savage Sisters shared google drive in the certifications folder.
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§ 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 all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Staff will complete the Fire prevention and emergency preparedness, including use of a fire extinguisher by 2/1/24. The employee that holds the position that DDAP recognizes as House Manager will be Fire prevention and emergency preparedness trained by 2/1/24, and all employees holding that position moving forward will have to receive that training within 60 days of being hired.
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§ 717.20(b) LICENSURE Resident Records
§ 717.20. Resident records.
(b) The licensee shall keep hard copy resident records in a locked cabinet and secure digital resident records on a protected data system.
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Observations
Based on the physical plant inspection, the recovery house failed to provide a hard copy of resident' dischagre records and provide proof that resident records were being secured in a locked cabinet or secured digitally on a protected data system.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Staff does currently have a resident roster that includes arrival and discharge date. This information is kept on our rental ledger. The employee that holds the position that DDAP recognizes as House Manager is responsible for maintaining the resident roster. This information is accessible at all times in Savage Sisters shared google drive in the resident ledger folder.
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§ 717.21(a) LICENSURE Resident Roster
§ 717.21. Resident roster.
(a) The licensee shall maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
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Observations
Based on a review of resident records, the recovery house failed maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency 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 will document any supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed in all resident records by 1/22/24. The employee that holds the position that DDAP recognizes as House Manager is responsible for maintaining these records in the Resident Ledger, which is accessible in Savage Sisters shared google drive in the Resident Ledger folder.
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§ 717.22(b)(2)(iii) 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:
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
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Observations
Based on a review of resident records, the recovery house failed to document any supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed 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 will document any supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed in all resident records by 1/22/24. The employee that holds the position that DDAP recognizes as House Manager is responsible for maintaining these records in the Resident Ledger, which is accessible in Savage Sisters shared google drive in the Resident Ledger folder.
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§ 717.22(b)(3)(iii) 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:
(iii) Demographic information.
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Observations
Based on a review of resident records, the recovery house failed to document all required basic personal data such as demographic information 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 has a digital demographic form. All residents have completed demographics. New residents will complete this upon arrival within 24 hours of arriving at the home. The employee that holds the position that DDAP recognizes as House Manager is responsible for ensuring these forms are filled out in within the time constraints listed. These Demographic forms are accessible in Savage Sisters shared google drive in the housing demographic folder.
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§ 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 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.
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Plan of Correction
All residents sign a form upon entry with emergency contact information and consent to inform contact in an emergency situation within 24 hours of arrival at the property. This form is digital the results are accessible in Savage Sisters shared google drive in the housing demographic folder. The employee that holds the position that DDAP recognizes as House Manager is responsible for maintaining these records.
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§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
Based on a review of resident records, the recovery house failed provided any discharge records in order to determine if written notification was given to the resident to end residency, if an opportunity to request the licensee reconsider to end residency was provided or if resident decided to end residency without providing a reason to the licensee.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
A digital form was created to provide information at the time of discharge for residents leaving the property. Included in that document is a spot to provide date and result of follow up with resident. The employee that holds the position that DDAP recognizes as House Manager is responsible fo ensuring residents being discharged are being provided this form and this information by the time they are discharged. Results from this for mare accessible in Savage Sisters shared google drive demographic folder.
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