INITIAL COMMENTS
|
This report is a result of an on-site initial licensure inspection conducted on March 7, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection UNP46701 ODAAT (One Day at a Time) Recovery House 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.
|
Plan of Correction
|
§ 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.
|
Observations
Based on a review of resident records, the recovery house failed to provide a written notification to the resident to end residency.Findings:In 4 out of 6 resident discharge records reviewed there was no written notification to end residency. These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The ODAAT Team has implemented the procedure on 03/08/2024 according to $717.23 Licensure.
The ODAAT staff will notify residents in writing of the decision to end residency. The notification of decision to end residency form will be completed and signed by resident and staff and placed in file once it is put into effect and not before that time. The resident may decide to end residency without providing a reason to ODAAT.
This will be reviewed by Director of Shelter Services, Christopher Deans biweekly to ensure that this process is happening as expected.
|
§ 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.
|
Observations
Based on a review of resident records, the recovery house failed to make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) 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 expectedFindings: In 5 out of 7 resident files the recovery house failed to notify the emergency contact within 12 hours of resident ' s departure.These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The ODAAT Team has implemented the procedure on 03/08/2024 according to $717.27 Licensure.
Notification to family or emergency contact identified at time of intake will occur no more than 12 hours after the resident decides to end residency, is hospitalized, dies, or does not return to the drug and alcohol recovery house as expected. This includes unsuccessful discharges and AWOL.
Documentation of this phone call will be maintained in the resident file.
If a resident has revoked their notification to family or emergency contact, it will be documented in the resident file.
If there are allegations of domestic abuse on resident by emergency contact, this information must be noted in their file on the related documents.
This will be reviewed by Director of Shelter Services, Christopher Deans biweekly to ensure that this progress is happening as expected.
|
§ 717.31(c)(4) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(4) An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on review of the resident records the recovery house failed to file an unusual incident report with the Department withing three business days following an unusual incident involving an event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel. Findings:Based on review of resident records the recovery house had presence of police and ambulance personnel and did not file an unusual incident report with the Department within 3 days. These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The ODAAT Team has implemented the procedure on 03/08/2024 according to $717.31©(4) Licensure. All incidents that occur onsite or off site will be documented on an incident report form any time there is the need for police, EMT or fire personnel to intervene.
ODAAT staff (Lead Supervisor, Directors and Designated Qualified Staff) will immediately notify SCA and then notify DDAP within 3 days through the provided(ERS) portal as an Unusual incident.
|