INITIAL COMMENTS
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This report is a result of an on-site recovery house complaint investigation conducted on November 9, 2022, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Friendship First was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717, which pertains to the recovery house.
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Plan of Correction
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§ 717.16 LICENSURE Fiscal Management
§ 717.16. Fiscal management.
The licensee shall develop and implement written policies and procedures for management of all funds received and expended by the drug and alcohol recovery house in accordance with standard accounting practices, including an itemized record and documentation of all revenues and expenditures.
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Observations
The recovery house failed to implement written policies and procedures to maintain a complete record of financial transactions such as, collection of fees, payments and deposits between the licensee and the residents in accordance with standard accounting practices , including an itemized record and documentation of all revenues and expenditures.
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Plan of Correction
Recovery house manager created an excel spreadsheet with all client
information to include revenue and expenses. The spreadsheet will
also contain arrival and departure dates, and emergency contact information.
Additionally there is a hard copy paper receipt in each individuals file as well as a copy of
payment given to each resident by recovery house manager. The spreadsheet is to be complete immediately but no later than December 1 2022 |
§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
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Observations
Following the request to review resident records on November 9, 2022, the recovery house failed to provide documentation of an individual record for each resident which must include:
All records obtained under 717.22.
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Plan of Correction
Each individual resident will be given a
folder that will be held under lock and key at arrival by the Recovery House Manager. It will include all signed paperwork, medication logs, paid rent receipts, drug test results and any additional paperwork. The recovery house manager will have this implementer immediately with all records up to date by December 1, 2022 |
§ 717.20(a)(3) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(3) Referrals to and from the drug and alcohol recovery house, if
applicable.
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Observations
Following the request to review resident records on November 9, 2022, the recovery house failed to provide documentation of an individual record for each resident which must include:
Referrals to and from the drug and alcohol recovery house.
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Plan of Correction
Each individual file will include referrals to and from the
recovery residence by the Recovery House Manager. The Recovery House Manager is to start keeping record immediately but no later then December 1, 2022 |
§ 717.20(b) LICENSURE Resident Records
§ 717.20. Resident records.
(b) The licensee shall keep hard copy resident records in a locked cabinet and secure digital resident records on a protected data system.
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Observations
Following the request to review resident records on November 9, 2022, the recovery house failed to keep hard copy resident records in a locked cabinet and secure digital resident records on a protected data system.
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Plan of Correction
All individual records will be kept under lock
and key at the residence by the Recovery House Manager. This is to begin immediately but no later then December 1, 2022 |
§ 717.21(a) LICENSURE Resident Roster
§ 717.21. Resident roster.
(a) The licensee shall maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
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Observations
Following the request to review resident records on November 9, 2022, the recovery house failed to maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
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Plan of Correction
A roster will be maintained on the excel
spreadsheet with arrival and departure dates by the Recovery House Manager. This will begin immediately but no later then December 1, 2022
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§ 717.22(a)(1) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(a) The licensee shall develop and implement written policies and procedures for beginning of residency which include:
(1) Residency criteria.
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Observations
Following the request to review resident records on November 9, 2022, the recovery house failed to provide documentation of an individual record for each resident which must include:
Consent to residency form
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Plan of Correction
Beginning and end of residency will
be documented and all paperwork pertaining to each individual will be kept under lock
and key by the Recovery House Manager. This is to begin immediately but no later then December 1, 2022. The Recovery House Manager will sign the Consent to Residency as well as the resident. |
§ 717.25(a)(1) LICENSURE Financial transactions
§ 717.25. Financial transactions.
(a) The licensee shall develop and implement written policies and procedures to maintain a complete record of collection of fees, payments and deposits between the licensee, the drug and alcohol recovery house or its employees and the resident or on behalf of the resident in accordance with standard accounting practices. The record must include:
(1) All fee deposits, resident fees and other monetary transactions between the drug and alcohol recovery house and the resident.
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Observations
The recovery house failed to implement written policies and procedures to maintain a complete record of financial transactions such as, collection of fees, payments and deposits between the licensee and the residents in accordance with standard accounting practices.
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Plan of Correction
All financial transactions will be
documented electronically as well as written with a paid receipt by the Recovery House Manager. These documents will be kept under lock and key by the Recovery House Manager. Financial transaction via electronic mail can be sent on request within 24 hours by the Recovery House Manger. This is to begin immediately but no later then December 1, 2022 |
§ 717.25(b)(5) LICENSURE Financial transactions
§ 717.25. Financial transactions.
(b) The licensee shall develop and implement written policies and procedures that prohibit the licensee, staff, volunteers or contractors of the drug and alcohol recovery house from:
(5) Directly or indirectly soliciting or accepting a commission, fee or anything of monetary or material value from residents, other related individuals, third-party entities or referral sources, beyond specified rent established in writing at the time of residency.
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Observations
The recovery house failed to implement written policies and procedures that prohibit the licensee, staff, volunteers or contractors of the drug and alcohol recovery house from all of the following:
(5) Directly or indirectly soliciting or accepting a commission, fee or anything of monetary or material value from residents, other related individuals, third-party entities or referral sources, beyond specified rent established in writing at the time of residency.
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Plan of Correction
No member of Friendship First is to
Directly or indirectly solicit or accept a commission, fee or anything of monetary or
material value from residents, other related individuals, third-party entities or referral sources, beyond specified rent established in writing at the time of residency. This has always been policy and will continue to be. Anyone breaching this policy will immediately be removed. This is to take effect immediately but no later then December 1, 2022 |