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, 517020 Surge Recovery 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
What we have done is organized folders and files for all staff and their records. We have planned evaluations with all staff on-going and every evaluation will be documented and placed into each staff members folders directly after they take place.
This POC was implemented by the executive director Martin Boyd |
§ 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.
|
Observations
Based on a review of resident records, the recovery house failed to have a complete client record. The recovery house failed to have resident orientation acknowledgement in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Our plan of correction was to take the resident handbook and insert all of the missing documents. We will provide the resident handbook along with all of the 17 bullet points that we re provided to us by DDAP, review them with every client, have them sign and date it, and these will be placed into the resident folder which will be kept in a filing cabinet in our locked office.
This POC will be over seen and executed by Martin Boyd the executive director. |