INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, DQRT6701 Unity Sober Living Homes was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing. 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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? 717.15(c) LICENSURE House Manager
§ 717.15. House Manager.
(c) The house manager shall complete at least 6 hours of training in one or more of the following areas within 6 months of becoming house manager, and annually thereafter:
(1) Fiscal policy.
(2) Administration.
(3) Program planning.
(4) Quality assurance.
(5) Program licensure.
(6) Personnel management.
(7) Confidentiality.
(8) Ethics.
(9) Trends in drug use and misuse.
(10) Developmental psychology.
(11) Interaction of addiction and mental illness.
(12) Cultural awareness.
(13) Sexual harassment.
(14) Relapse prevention.
(15) Substance use disorders.
(16) Peer support or mutual aid groups.
(17) Best practices for medication control and self-administration.
(18) Infection control.
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Observations
Based on a review of staff record, the recovery house failed to have staff complete at least 6 hours of training in one or more of the DDAP required areas of training within 6 months of becoming house manager.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Unity Sober Living Homes CEO will ensure staff and house managers will complete the required training within six months of hire and yearly thereafter, Unity Sober Living Homes CEO will ensure the trainings are up to date and all files will be reviewed every 90. Current trainings certificate will be kept in employee oathtrack chart, to be completed by 06/01/2024
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§ 717.18(c)(4) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
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Observations
Based on a review of staff records, the recovery house failed to have staff complete the Fire prevention and emergency preparedness, including use of a fire extinguisher within the first 90 days of hire in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Unity Sober Living Homes CEO will ensure mal and female directors of operations will complete the required fire extinguisher certification by 06/01/2024
Unity Sober Living Homes CEO will review these certifications every 90 days to ensure all employee files are up to date, complete certifications will be kept in the employee file |
§ 717.20(a)(2) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(2) Consent to residency form.
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Observations
Based on a review of resident records, the recovery house failed to obtain written acknowledgement by residents that they are required to participate in treatment, self-help groups or other drug and alcohol recovery supports in seven of seven resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Unity Sober Living Homes CEO has ammended our "intake packet" to be signed by each resident, to include an acknowledgement by residents of their requirement to engage in treatment, this packet will be uploaded to each residents oathtrack file, effective immdediately |
§ 717.22(b)(5) 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:
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
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Observations
Based on a review of resident records, the recovery house failed to disclose and have resident sign the notification of emergency form within 24 hours of arrival which identifies situations when recovery house staff may notify the resident ' s emergency contact in seven of seven resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Unity Sober Living Homes CEO, effective immediately has updated our "intake packet" which is signed by all residents to include the residents rights, notification of emergency contact, last known address, and termination of residency. The resident is offered a copy of all forms signed. |