INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on April 28, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 517013 Merakey Fresh Start 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 complete staff record. The recovery house failed to have a mechanism to collect feedback on completed training in four of four staff records.
Staff # 101 was hired on June 25, 2008. Feedback mechanism form not found in the employee record.
Staff # 102 was hired on September 22, 2014. Feedback mechanism form not found in the employee record.
Staff # 103 was hired on July 18, 2022. Feedback mechanism form not found in the employee record.
Staff # 104 was hired on February 26, 2018. Feedback mechanism form not found in the employee record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
A document has been created to collect feedback from all employees, for all of the required DDAP trainings. This document will ask employees to list:
1. Pros of the training?
2. Cons of the training?
3. Did you find this training helpful for your job?
4. What did you learn?
5. How would you improve this training?
This document will become part of the employee file and will be reviewed by the Program Manager and Program Director in an effort to see if there are areas we can improve the trainings we offer our employees.
This document will be incorporated once approved by DDAP. |
§ 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 resident sign notification to family member or emergency contact forms in six of seven records.
Client # 102 was admitted on June 24, 2022 and discharged on October 06, 2022. Notification to family member or emergency contact form not found in the client record.
Client # 103 was admitted on October 03, 2022 and discharged on April 01, 2023. Notification to family member or emergency contact form not found in the client record.
Client # 104 was admitted on December 06, 2022 and discharged on March 30, 2023. Notification to family member or emergency contact form not found in the client record.
Client # 105 was admitted and discharged on April 08, 2022. Notification to family member or emergency contact form not found in the client record.
Client # 106 was admitted and discharged on July 15, 2022. Notification to family member or emergency contact form not found in the client record.
Client # 107 was admitted and discharged on November 04, 2022. Notification to family member or emergency contact form not found in the client record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Our emergency contact forms were amended to include the following statement:
"I understand that the recovery house will notify my emergency contact in the event that I am discharged from the recovery house, do not return to the recovery house overnight, and/or my whereabouts are unknown for more than 12 hours".
Recovery House staff will be made aware that they need to notify emergency contacts in these situations and document their attempt to reach out on the Emergency Contact Log Form which can be found in each resident's file.
In addition, a letter outlining the end of residency will be provided to each resident and a copy will be stored in each resident's file as well.
These documents and these processes will be implemented once approved by DDAP. |