INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection C37W6701 YMCA of Reading Berks County, 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(a)(1) LICENSURE Resident Rights
§ 717.19. Resident rights.
(a) The licensee shall develop and implement written policies and procedures on resident rights which must include:
(1) Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority.
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Observations
Based on review of the ten resident records the recovery house failed to provide resident rights.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Following the review of resident records, we have updated our Clients Rights documentation to ensure full compliance. Effective June 2, 2025, the updated Clients Rights will be included in all Clients files. Staff have been informed of these updates, and measures are in place to ensure continued adherence to resident rights. |
§ 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 provide a written notification to the resident stating the decision to end residency.
Findings:
In 2 out of 4 resident discharge records the recovery house failed to provide a written notification to the resident stating the decision to end residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Following the review of clients discharge records, we have implemented corrective measures to ensure full compliance with DDAP regulations regarding written notification of residency termination.
Corrective Actions Taken:
Effective June 2, 2025, all clients will receive a formal written notification when a determination to discharge/end residency is made.
A standardized termination notice template has been developed and incorporated into our discharge procedures.
Staff have been trained to ensure consistent documentation and adherence to this policy moving forward.
Periodic internal audits will be conducted to verify compliance. |
§ 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 make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) 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.
In 2 out of 4 resident discharge records the recovery house failed to notify the emergency contact within 12 hours of residents departure.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
Following the review of clients discharge records, we have implemented corrective measures to ensure full compliance with DDAP regulations regarding timely notification of emergency contacts.
Corrective Actions Taken:
Effective June 2, 2025, staff will make at least one attempt to notify the clients emergency contact immediately and no later than 12 hours after the client ends residency or does not return as expected.
A New Emergency Contact Form has been developed and incorporated into discharge procedures.
Staff have been trained on proper documentation and adherence to this policy moving forward.
Regular internal audits will be conducted to verify compliance. |