INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 09/08/2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 120030 79 Blueridge Drive LLC 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(c)(1) 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:
(1) Cardiopulmonary resuscitation (CPR) certification.
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Observations
Based on a review of staff records, the recovery house failed to have staff complete the First Aid certification within the first 90 days of hire in staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
#0190 House manager will ensure that self and volunteer have completed the certification for first aid by 12/1/2023.
House manager will make sure any new hire have completed the first Aid certification within the 90 days of hire.
House manager will send certification to DDAP upon completion by 12/1/2023. |
§ 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 tuberculosis and sexually transmitted diseases training using a department approved curriculum within the first 90 days of hire in staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager will insure that self and volunteer for 79 Blue Ridge Dr. LLC do the training for HIV/AIDS, STD/TB within the 90 days (12/3/2023). House Manager will send Certificates to DDAP for completed approved curriculum on HIV/AIDS, and STD/TB and will make sure any new hires have complete certificates within the DDAP time frame. |
§ 717.18(c)(4) 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:
(4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
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Observations
Based on a review of staff records, the recovery house failed to have staff complete the Fire prevention and emergency preparedness, including use of a fire extinguisher within the first 90 days of hire in staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
#0193 House manager will ensure all staff including self-completes the fire prevention, emergency preparedness and use of fire extinguisher videos online within the 90 days (12/1/2023). House manager will ensure any new hires complete the same within 90 days of hire to 79 Blue Ridge Dr. LLC.
House manager will send any documentation to DDAP on or before 12/1/2023.
House manager will make sure all employees continue to stay up to date on these yearly. |
§ 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
#0201 House manager put the resident's rights into intake packet and handbook. House manager is the only one printing out intake packets and handbooks to ensure nothing is left out. House manager and volunteer will go through all residents' packets to ensure they aren't missing any important papers especially resident's rights by 9/21/2023.
House manager and volunteer will do a monthly check (last Friday of the month) on all resident's folders to ensure paperwork is in order. |
§ 717.22(b)(2)(i) 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:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(i) Drug and alcohol recovery house rules, including a method to record residents' expected return time to the drug and alcohol recovery house.
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Observations
Based on a review of resident records, the recovery house failed to have resident orientation acknowledgement in resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
#0236 House manager and volunteer will make sure resident orientation is signed and initialed that they received an orientation, handbook and rules as well as keeping the sign in and out sheets.
House manager and volunteer will collect sign out sheets monthly and download them onto a thumb drive marked for that house.
House manager will keep thumb drives, marked with house number and dated at office incase needed for future reference. |
? 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 a review of resident records, the recovery house failed to document all basic personal data within 24 hours of arrival in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
#0245 House manager and volunteer will ensure each intake packet is completely filled out with basic personal data including beginning of residency, name with residents initialing packets within 24 hours of arriving. House manager and volunteer will ensure all packets are initialed and completed by reviewing all packets by 9/21/2023. |
§ 717.22(b)(3)(vii) 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:
(3) Basic personal data including:
(vii) Emergency contact.
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Observations
Based on a review of resident records, the recovery house failed to complete all basic personal data including emergency contact form within 24 hours of arrival in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
#0251 House manager and volunteer will make sure that every resident lists an emergency contact name and number within 24 hours of arriving at 79 Blue Ridge Dr. LLC. House manager and volunteer will go through all residents' records by 9/21/2023 and make sure each has an emergency name and number on it. House manager and volunteer will do a monthly check (last Friday of each month) of residents folders to ensure all information is correct. |
§ 717.29(d)(1)(viii) LICENSURE Physical plant standards - Sleep accomodation
§ 717.29. Physical plant standards.
(d) Sleeping accommodations.
(1) Each drug and alcohol recovery house bedroom must have the following:
(viii) Ventilation by operable windows or have mechanical
ventilation.
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Observations
Based on the physical plant inspection, the recovery house failed to have a ventilation by operable window or have mechanical ventilation within one of the resident bedrooms.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager will remove all beds and bedding from basement of #C47H6701 and send pictures to DDAP. House manager will make sure that all bedrooms have a natural light source. House manager will move the resident to another bedroom that has been inspected on 9/15/2023 or sooner if possible.
House manager walked through all the bedrooms again to make sure all have a natural light source and will continue to make sure residents needs are met. |
§ 717.29(d)(1)(ix) LICENSURE Physical plant standards - Sleep accomodation
§ 717.29. Physical plant standards.
(d) Sleeping accommodations.
(1) Each drug and alcohol recovery house bedroom must have the following:
(ix) A window with a source of natural light.
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Observations
Based on the physical plant inspection, the recovery house failed to have a window with a source of natural light in one of the resident bedrooms.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
We are going to open up wall to allow natural light into the #2 bedroom. We will be moving two residents before starting construction and it will be completed by 12/1/2023.
House Manager will make sure job is complete and that residents needs are taken care of during construction. House manager will take pictures and send to DDAP when construction is completed.
House manager will be vigilant in making sure no bedrooms moving forward are without natural light access. |