INITIAL COMMENTS
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This report is a result of an renewal on-site licensure inspection conducted on January 11, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 136001 Why Not Prosper 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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§ 717.17(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.
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Observations
Based on a review of staff files, the recovery house failed to have the PA State Police Criminal History Check in three of five records.
Employee # 3 - was hired on December 15, 2022, and was in the position of Admin Staff at the time of the inspection.
Employee # 4 - was hired on June 10, 2019, and was in that position of House Monitor at the time of the inspection.
Employee # 5 - was hired on June 19, 2019, and was in that position of House Monitor at the time of the inspection.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Going forward each volunteer and employee hired will have a PA State Criminal History Check before working at WNP. House manager will inspect files daily and check status of background checks. |
§ 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 files, the recovery house failed to conduct and document an evaluation of the training plan in one of five records.
Employee # 5 - was hired on June 19, 2019, and was in that position of House Monitor at the time of the inspection.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Every staff at the point of hire during orientation will get a list of required trainings, the Relias website and a completion date within 2 weeks of hire. The house manager has set up a list for each employee to track their completed trainings. On a monthly basis the house manager will review the files to make sure each employee is in compliance with required 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 files, the recovery house failed to have the employees complete the CPR training within 90days of becoming employed in one of five records.
Employee # 5 - was hired on June 19, 2019, and was in that position of House Monitor at the time of the inspection.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Every staff at the point of hire will be required to complete CPR training via the Relias website within 2 weeks of hire. We have also build a relationship with the Red Cross where we can send employees for training in a timely fashion. |
§ 717.18(c)(2) 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:
(2) First aid training, including training on overdose reversal medication.
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Observations
Based on a review of staff files, the recovery house failed to have the employees complete the First Aid and overdose reversal medication training within 90days of becoming employed in one of five records.
Employee # 5 - was hired on June 19, 2019, and was in that position of House Monitor at the time of the inspection.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Every staff at the point of hire we have First Aid training within 2 weeks of hire via the Relias website or through our partnership with Red Cross. |
§ 717.18(c)(3) 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:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on a review of staff files, the recovery house failed to have the employees complete the sexually transmitted diseases training in two of five records and the HIV/AIDS training in one of five records within 90 days of becoming employed.
Employee # 4 - was hired on June 10, 2019, and was in that position of House Monitor at the time of the inspection.
Employee # 5 - was hired on June 19, 2019, and was in that position of House Monitor at the time of the inspection.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Every staff at the point of hire during orientation will get a list of required trainings, the Relias website and a completion date within 2 weeks of hire. Mandatory HIV/AIDS training will be required by hired staff and volunteers within 2 weeks of hire via Relias website. The house manager has set up a list for each employee to track their completed trainings. If training is not completed within 2 weeks staff start date will be delayed. On a monthly basis the house manager will review the files to make sure each employee is in compliance with required trainings.
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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 files, the recovery house failed to have the employees complete the Fire prevention and emergency preparedness, including use of a fire extinguishertraining within 90days of becoming employed in one of five records.
Employee # 4 - was hired on June 10, 2019, and was in that position of House Monitor at the time of the inspection.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Every staff at the point of hire will have
Fire safety training including use of fire extinguisher training within 90 days at WNP. House manager will update files during monthly inspection of employee's charts. |
§ 717.22(b)(1) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
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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 have the resident sign a disclosure of resident criteria for beginning and ending residency within 24 hours of arrival in three of three records.
Client # 101 was admitted on October 20, 2022. There was no form of disclosure to the resident of the criteria for beginning and ending residence in the resident ' s record.
Client # 102 was admitted on November 11, 2022. There was no form of disclosure to the resident of the criteria for beginning and ending residence in the resident ' s record.
Client # 103 was admitted on November 18, 2022. There was no form of disclosure to the resident of the criteria for beginning and ending residence in the resident ' s record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Immediate action has taken place and WNP has created a Disclosure of resident criteria form and every resident will complete the form within first hours of admission and arrival at WNP. Form will be completed by House Manager and in her absence clinical support. The residents already enrolled prior at WNP have completed the disclosure. We printed off all the new polices and had the prior residents sign and date the new polices and we inserted the completed documents in their files. |
§ 717.22(b)(4) 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:
(4) Consent to residency.
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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 have the resident sign a consent to residency within 24 hours of arrival in three of three records.
Client # 101 was admitted on October 20, 2022. There was no consent to residency form in the resident ' s record.
Client # 102 was admitted on November 11, 2022. There was no consent to residency form in the resident ' s record.
Client # 103 was admitted on November 18, 2022. There was no consent to residency form in the resident ' s record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
A new packet has been created to include the consent to residency. Residences will sign consent form within 24 hours of arrival with House manager and in her absence Clinical support. We went through each prior residences at WNP and had them complete the new packet created and sign and date the consent to residency form. Going forward the house manager will manage the charts on a monthly basis and keep them up to date. |