INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection LGDC6701 Sarah J. Bentley 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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§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
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Observations
Based on a review of resident records, the recovery house failed to have a complete individual record.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation will maintain all recovery house resident files at 2001 N. Front St., Bldg 3, Suite 334, Harrisburg PA 17102. The Office Manager will be responsible for maintaining complete client records. The Clinical Supervisor will review the documents for accuracy and completeness during unannounced quarterly reviews. |
§ 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
The licensee failed to maintain a resident roster that identifies the date of each resident's beginning and end of completion of residency. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation created and adopted a new form to track the name, bed assignment, admission, and discharge date of all clients/residents admitted to the Recovery House program. The form was implemented on October 1, 2024. To prevent recurrence, the CEO will review the roster monthly to ensure that it accurately reflects any/all census changes.
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§ 717.29(b)(1) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(1) Keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
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Observations
Based on review of the physical plant inspection the recovery house failed to keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All debris and unsafe materials have been removed from the yard on 10/01/2024. The living space within the recovery home has been cleaned and sanitized on 10/01/2024. A house meeting was held on 10/01/2024 to discuss the completion of required chores to ensure clean and sanitary sleeping rooms. The recovery house has adopted a new safety and sanitation checklist. House staff members will verify the presence of all fire extinguishers during daily, documented, physical plant rounds. |
§ 717.30(b)(2) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(2) Maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
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Observations
Based on the physical plant inspection the recovery house failed to maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
To ensure the client's safety, emergency escape ladders will be affixed to the side of the building by Friday, October 4, 2024. |
§ 717.30(d)(1) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(1) Maintain at least one portable fire extinguisher with a minimum of an ABC rating for every 2,000 square feet of space and fraction of it on each floor.
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Observations
Based on the physical plant inspection the recovery house failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating for every 2,000 square feet of space and fraction of it on each floor. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation ordered a new ABC-rated fire extinguisher for use in the residential facility on 10/02/2024. With the addition of this fire extinguisher, two (2) operable ABC-rated fire extinguishers are now in the residence on 10/02/2024. House staff members will verify the presence of all fire extinguishers during daily, documented, physical plant rounds.
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