INITIAL COMMENTS
|
This report is a result of an initial on-site licensure inspection conducted on 04/28/2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 517004 Stop & Surrender 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.
|
Plan of Correction
|
§ 717.18(b) LICENSURE Training
§ 717.18. Training.
(b) The licensee shall conduct and document an evaluation of the training plan annually.
|
Observations
Based on a review of staff records, the recovery house failed to have a complete staff record. The recovery house failed to conduct and document an evaluation of the training plan annually in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The regional director or program director/house manager will ensure that annual evaluation of training needs with a training plan to support those needs in each employee file. |
§ 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.
|
Observations
Based on a review of resident records, the recovery house failed to have a complete client record. The recovery house failed to obtain written acknowledgement by residents that they have received notice of their rights in four of four records.
Client # 101 was admitted on July 15, 2022. Acknowledgement of residents right form not found in the client ' s record.
Client # 102 was admitted on July 05, 2022 and discharged on September 25, 2022. Acknowledgement of residents right form not found in the client ' s record.
Client # 103 was admitted on July 13, 2022 and discharged on August 08, 2022. Acknowledgement of residents right form not found in the client ' s record.
Client # 104 was admitted on July 14, 2022 and discharged on July 21, 2022. Acknowledgement of residents right form not found in the client ' s record.
|
Plan of Correction
The recovery house (regional director/program director/house manager) has updated our resident handbook to include the residents rights and an acknowledgment signature page for each resident and a witness to sign upon admission to the recovery residence. This acknowledgement will be kept in each resident's file. |