INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection EXTR6701 Easy Does It, 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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§ 717.22(b)(1) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
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Observations
Based on review of the resident records the licensee failed to complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
Findings: In 7 out of 16 records reviewed the resident signature was missing for 717.22 (2) (i), (iv), (v), (vi) which is contained in the orientation handbook.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager will ensure that within 24 hours of admission, each resident will sign a signature sheet that the resident acknowledges receipt of the resident handbook which contains all elements of the cited regulation.
The House Manager will ensure that the signature sheet is contained in the resident record by conducting routine record reviews/audits.
This policy is in effect as of 4/11/2025.
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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 a written notification to the resident stating the decision to end residency.
Findings:
In 3 out of 7 resident discharge records the recovery house failed to provide a written notification to the resident stating the decision to end residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager will create and implement a notification to end residency form.
The House Manager will ensure that each resident is notified of the reason and timeframe for discharge and will attempt to obtain the resident's signature at time of discharge.
The House Manager will ensure that the notification to end residency form is contained in the resident record by conducting routine record reviews/audits.
This policy is in effect as of 4/11/2025.
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