INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 30, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 0X7C6701 Treatment Trends 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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§ 717.20(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
Based on a review of resident records, the recovery house failed to maintain an individual record for each resident which must include: All records obtained under 717.22 (b).
Findings:
In 1 out of 6 resident record review documentation was missing from resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
To address this deficiency, Fiscal Manager completed missing documentation from client record on 06/04/24 and uploaded it into our Electronic Medical Record. For future client records, Quality Assurance Coordinator will submit current paper forms to our Electronic Medical Record and make it a part of Allentown Recovery House initial encounter. Quality Assurance will submit this request to our EMR by 06/28/24. |
§ 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 1 out of 3 resident discharge records the recovery house failed to notify the emergency contact within 12 hours of residents departure.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
To remain in compliance with notifying the resident's emergency contact, Quality Assurance altered the 'Discharge/Exit Report' on 08/29/23, which includes a check box asking if the Resident's emergency contact was notified. In addition to our 'Discharge/Exit Report' form, the House Manager will document the attempt/phone call in our EMR through Patient Communication. House Manager was informed of this new procedure on 06/10/24. Implementation is effective on 06/10/24.
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