INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on 04/28/2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 517022 One Day At A Time 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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§ 717.18(b) LICENSURE Training
§ 717.18. Training.
(b) The licensee shall conduct and document an evaluation of the training plan annually.
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Observations
Based on a review of staff records, the recovery house failed to have a complete staff record. The recovery house failed to conduct and document an evaluation of the training plan annually in all staff records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The ODAAT Team has developed and will require the completion of a professional development checklist for all of its team members. The development checklist lists all required trainings for DDAP training compliance and provides the timeline in which trainings need to be completed. The professional development will be required for team members to submit quarterly to their immediate supervisor to check and ensure progress. The Program Director will also conduct routine audits to ensure that team members are attending required trainings. |
§ 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 have a complete resident record. 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 all resident records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The ODAAT Team will conduct individual orientation sessions with each participant when the client first arrives to the facility. During this orientation session, the resident handbook will be reviewed with the participant to ensure they do not have any questions and they fully understand program expectations. During this orientation residents will be asked for signed confirmation that they have received and reviewed the resident handbook. Additionally, program participants will be asked for signed confirmation of their consent of their residency with the program. Both signed confirmations will be stored in the client file onsite. The Program Director will conduct regular audits to ensure this is being completed for all clients. |