INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection RTXI6701 Safe Haven 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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§ 717.21(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 review of the resident records the recovery house failed to have a resident roster.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Resident roster has been created (Excel file) listed are the name, beginning of residency date and end of residency date. This roster shall be maintained by the prospective Director of the facility. The Director of Transitional Living is responsible for implementation of the corrective action. Action completed 05.28.2025. |
? 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 review of resident records the recovery house failed to collect a full basic personal data.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All current resident records have been reviewed by the prospective Director. The missing "drug and alcohol history" and "Emergency medical contact" sections have been completed. It is the responsibility of the prospective Director to monitor and correct any missing information within the resident records in a timely fashion. Corrective action to be completed 06.06.25 |