INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection CHGX6701 Daystar Center for Spiritual Recovery 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
Based on a review of resident records the recovery house failed to notify the residents of their rights or obtain written acknowledgment from the residents that they have received notice of their rights.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In effort to address citation 717.19(b)
Resident Rights:
Beginning 4/26/2024. All current residents were immediately met with and notified of their residential rights. A copy of this document was signed by residents. They were given a copy of this signed document and a copy was entered into their chart.
House Manager was trained on the importance of informing residents of their rights and obtaining written acknowledgment.
House Manager will conduct weekly audits of residents charts to ensure that Daystar remains in compliance with Policy 717.19(b) Residents Rights.
Program Director will review monthly with House Manger to ensure this policy implemented and maintained.
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? 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 obtain all the required basic personal data from the residents.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In effort to address citation 717.22(b) (3)(i)
Beginning of Residency:
On 4/26/2024 All current residents records were updated to include all missing personal documentation. This information was reviewed with and signed by current residents.
House Manager was trained on the importance of collecting complete personal data prior to a resident entering into the recovery house.
To ensure compliance with policy 717.22(b)(3)(i) Beginning of Residency.
House Manager will conduct weekly chart audits to make sure that personal data is updated and complete.
Program Director will meet with House Manager monthly to ensure that this policy is implemented and maintained.
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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 to notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In an effort to address citation 717.23
Notification of decision to end residency:
On 4/26/2024 all current residents were made aware of policy 717.23, notice of the rights of the Daystar Recovery House to end residency with resident. Residents were also educated on their rights to appeal this decision.
House Manager received education and training on this policy.
In the future, House Manager will meet with every resident prior to the decision to terminate their residency. During this meeting resident will be given the opportunity to appeal the decision.
Program Director will meet with House Manager prior to any decision to terminate residency of resident. Program Director will also complete monthly record check to ensure that all documentation was complete.
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