INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, BYJ36701 Stop and Surrender Wayne Ministries 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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§ 717.19(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 seven in seven resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager/regional director will ensure that all current residents sign the notification of emergency form and place in each resident file by 04/12/2024. Also, all future admissions will sign the notification of emergency contact form and a copy will be kept in the resident's file. |
§ 717.22(b)(5) 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:
(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 disclose and have resident sign the notification of emergency form within 24 hours of arrival which identifies situations when recovery house staff may notify the resident ' s emergency contact in seven of seven resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager/regional director will ensure that each resident receives a copy of the residents rights within seven days of admission to the recovery house. The signed acknowledgement will be kept in each resident file. Also, all current residents will be provided a copy of their rights and the signed acknowledgement with be added to their file by 04/12/2024. |