INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 01, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 74XW6701 Gibson Foundation 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
A survey has been implemented for all new hires and staff to take after completing a training. The site manager will follow up with all staff to ensure all trainings needed are taken. The program manager will also check staff files to make sure trainings are being completed.
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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
The recovery house manager will ensure all current records are up to date and ensure all staff completes all required trainings within the allocated training period Moving forward all records will be reviewed every three months to ensure all records are in compliance.
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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
All staff at each site has been informed that the proper documentation must be in the resident's records, including the residents' rights. Immediately going forward the site manager will review all current and new resident's records to ensure the proper documentation has been submitted which includes acknowledgement from resident that the rights were received. |
§ 717.20(a)(2) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(2) Consent to residency form.
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Observations
Based on a review of resident records, the recovery house failed to obtain written acknowledgement by residents that they are required to participate in treatment, self-help groups or other drug and alcohol recovery supports 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 are required to sign the rules and regulations which includes that they are required to go to out-patient treatment, attend AA/NA support groups and site trainings, groups and workshops. The site manager will instruct all staff that does intake to obtain a signature of acknowledgment from each new resident and assist with connecting them to resources if needed. |