INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection T3Y06701 Keep It Green 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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§ 717.23 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 one of three discharged resident records reviewed, the facility failed to provide 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
Current and any new Office Managers will be coached on which instances require notification as well as the proper documentation. Residents that move without notice or forwarding address will have a notice filled out and a copy will be sent to emergency contact as well as entered in their file. In the event an address is unavailable, staff will discuss with emergency contact during that notification process and mail a copy to the address furnished at that time.
The Director of Operations will be responsible to check discharged resident files for documentation prior to placing each discharged resident file in inactive clients. The Director of Operations will also audit all discharged files monthly to ensure no files have been missed.
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