INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, XTRT6701 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)(2)(i) 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:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(i) Drug and alcohol recovery house rules, including a method to record residents' expected return time to the drug and alcohol recovery house.
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Observations
Based on review of the resident records, the recovery house failed to have documents signed within 24 hours of arrival.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
After reviewing resident records, we discovered 8 former (discharged) resident records did not contain the resident's signature on a form called "Acknowledgment of Resident Handbook/Rights/Transportation." (This form satisfies the cited regulation at 717.22(b) when signed within 24 hours of beginning of residency.). The omission of this resident signed form was isolated to the 8 discharged resident records during a time when we transitioned our resident records from a paper format to an electronic medical records (EMR) system.
Since we have converted to an EMR system, we have verified that all current resident records have the signed form, satisfying the cited regulation. Additionally, we have a mechanism in our EMR system known as a "forms batch" that automatically populates all required forms to be reviewed and signed by residents at the beginning of residency (on day of admission to the recovery house). The forms batch includes the "Acknowledgment of Resident Handbook/Rights/Transportation" form. This forms batch is working and ensures that we are complying with the cited regulation. The DDAP designated House Manager (EDI's Director of Operations) is also checking each new resident record to ensure that all forms are present and signed following each admission.
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