INITIAL COMMENTS
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This report is a result of an renewal on-site licensure inspection conducted on October 10, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, HGSG6701 Unity Sober Living was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
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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 view of staff records, it was determined the house manager fail to complete at least six hours of training within 6 months of becoming house manager, and annually thereafter.
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Plan of Correction
Unity Sober Living director will add the necessary hours of DDAP trainings to the new hire packet immediately. For all existing staff members the required hours of trainings have been scheduled and will be renewed on a twice annually basis where needed and will be completed before the end of the calendar year. |
§ 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 it was determined the recovery house failed to conduct and document an evaluation of the staff training plan annually.
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Plan of Correction
Unity Sober Living Director will immediately create and update staff personnel files, which will contain a review of the necessary trainings, to be reviewed on an annual basis and will be immediately completed for any new hire on the date of hire. These files will be available as soon as the employee completes the mandated trainings. |
§ 717.18(c)(1) 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:
(1) Cardiopulmonary resuscitation (CPR) certification.
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Observations
Based on a review of staff records it was found the recovery house staff failed to complete Cardiopulmonary resuscitation (CPR) certification within 90 days of becoming an employee.
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Plan of Correction
Unity Sober Living Director has scheduled CPR training for all existing employees, and has given each employee thirty days to present their completion certificates for their employee files. |
§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
Based on a review of resident records, the recovery house failed to notify a resident of their discharge in writing. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Unity Sober Living Director has created, and immediately implemented and "end of residency" form, the form states, the date/time and reason for discharge and will be signed or electronically sent to anyone discharged from the program and their emergency contact, upon discharge |
§ 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 document at least one attempt to notify the 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. These findings were reviewed with recovery house staff during the renewal inspection process.
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Plan of Correction
Unity Sober Living Homes director has created and immediately implemented and "end of residency" form which will be sent electronically to anyone discharged from the program and their emergency contact, listing the date/time and reason for discharge. This form has been added to our electronic filing system. |