INITIAL COMMENTS
|
This report is a result of an initial on-site licensure inspection conducted on April 28, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 517002 Joy of Living Recovery Program 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.
|
Plan of Correction
|
§ 717.17(b)(7) LICENSURE Personnel Management
§ 717.17. Personnel management.
(b) The written policies and procedures must include:
(7) Completion of a Pennsylvania State Police Criminal history record check for the house manager, all staff and volunteers before engaging in work at the drug and alcohol recovery house.
|
Observations
Based on a review of staff records, the recovery house failed to have a complete staff record. The recovery house failed to have a completed Pennsylvania State Police Criminal history record check for staff in four of four records.
Staff # 101 was hired on July 01, 2005. Pennsylvania State Police Criminal history record check not found in the employee record.
Staff # 102 was hired on March 09, 2023. Pennsylvania State Police Criminal history record check not found in the employee record.
Staff # 103 was hired on September 20, 2020. Pennsylvania State Police Criminal history record check not found in the employee record.
Staff # 104 was hired on May 22, 2020. Pennsylvania State Police Criminal history record check not found in the employee record.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Criminal history records have been filed in staff folders effective 5/2023. The house manager has reviewed all staff files to ensure Criminal History checks are included in employee records. The house manager will be responsible for spot checks to ensure that all staff records contain background checks moving forward. |
§ 717.19(b) LICENSURE Resident Rights
§ 717.19. Resident rights.
(b) The licensee shall obtain written acknowledgement by residents that they have received notice of their rights.
|
Observations
Based on a review of resident records, the recovery house failed to have a complete client record. The recovery house failed to obtain written acknowledgement by residents that they have received notice of their rights in seven of seven records.
Client # 101 was admitted on September 07, 2022 and discharged on April 04/2023. Acknowledgement of residents right form not found in the client ' s record.
Client # 102 was admitted on September 29, 2022 and discharged on March 15, 2023. Acknowledgement of residents right form not found in the client ' s record.
Client # 103 was admitted on October 28, 2022 and discharged on April 11, 2023. Acknowledgement of residents right form not found in the client ' s record.
Client # 104 was admitted on December 12, 2022 and discharged on April 02, 2023. Acknowledgement of residents right form not found in the client ' s record.
Client # 105 was admitted on January 17, 2023. Acknowledgement of residents right form not found in the client ' s record.
Client # 106 was admitted on January 11, 2023. Acknowledgement of residents right form not found in the client ' s record.
Client # 107 was admitted on February 23, 2023. Acknowledgement of residents right form not found in the client ' s record.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Joy of Living Resident Handbook has been revised to include client rights effective 4/2023. The house manager has reviewed all current resident records to ensure the residents have received notice of their rights. Going forward the resident Handbook now includes notification of client rights. The House manager will do random record checks to ensure all resident records contain acknowledgment of their rights. |