INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 6Q2Z6701 Sunny Day Sober Living, LLC 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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§ 717.27 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 3 out of 4 discharged records reviewed the recovery house failied to document that the resident ' s emergency contact was notified 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.
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Plan of Correction
Sunny Day Sober Living management has implemented a checklist / log for each resident that is added to a binder when they begin residency. This binder came into use on 7/1/2024. Included in the checklist is a column for "Unusual Incident Emergency Contact Notified, Date and Time & Exit from Services Emergency Contact Notified". The house manager will document the contact made with date and time. This information will also be documented in the notes section of RentRedi, our rent / information electronic tracking system. The binder will be kept in a locked cabinet in the house manager's office.
EACH AND EVERY TIME A GUEST DOES NOT RETURN OR EXITS SERVICES, THE HOUSE MANAGER WILL CONTACT THE EMERGENCY CONTACT IMMEDIATELY AFTER 12 HOURS OF ABSENCE HAS OCCURRED. THE HOUSE MANAGER WILL DOCUMENT EACH OF THESE CALLS IN THE ABOVE MENTIONED LOG. THIS INFOMATION WILL BE OBTAINED FROM THE EMERGENCY CONTACT INFORMATION LOCATED ON THE GUEST'S CONSENT TO RESIDENCY FORM. THE EMERGENCY CONTACT INFORMATION WILL BE UPDATE ON THE BACK OF SAID FORM ANYTIME THAT IT CHANGES. |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
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Observations
Based on a review of the fire extinguishers located throughout the property, the recovery house failed to have the kitchen fire extinguishers inspected and approved annually by the local fire department or fire extinguisher company.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
An additional fire extinguisher was purchased from Hartman Fire Equipment. It is pressure tested and tagged. It has been bracket mounted in the kitchen. This is addition to four other extinguishers located in each floor of the home.
AS INDICATED ABOVE SAID EXTINGUISHER WAS PURCHASED AND HUNG ON 6/15/2024 |