INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on March 5, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection W4VS6701 Libertae, Inc 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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§ 717.23 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.
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Observations
Based on a review of resident records, the recovery house failed to provide written notification to end residency in 2 records.Findings:In 2 out of 5 resident discharged records, resident records did not have notification to end residency. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
It is the policy of Libertae, Inc. to provide written notification of intent to end residency in the recovery house. Whenever it is determined that the residency of an individual in the recovery house is to be terminated, written notification of same shall be provided by the house manager. A copy of the written notification shall be filed in the resident's records.
The deficiency shall be corrected by April 3, 2024, and maintained by the house manager, who has been advised of this requirement. A review of resident records will be conducted quarterly to ensure that the deficiency does not reoccur.
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§ 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.
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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 expected.Findings:In 2 out of 5 resident discharge records the recovery house failed to notify the emergency contact within 12 hours of resident departure. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
It is the policy of Libertae, Inc. to make at least one attempt to notify a resident's emergency contact immediately, and in no event more than 12 hours after the resident decides to end residency or does not return to the recovery house as expected.
It is the responsibility of the house manager to attempt to make this notification and to document same in the resident's records. The deficiency will be corrected By April 3, 2024, and maintained by the house manager. A record audit will be conducted quarterly by the supervisor of the house manager to ensure that the correction is sustained. |