INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on March 15 , 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection C37W6701 YMCA of Reading and Berks County 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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§ 717.27 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 make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) 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.
Findings:
In 3 out of 6 resident discharge files the recovery house failed to notify the emergency contact within 12 hours of residents departure.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
As of 3/25/24, The plan of correction will be as follows: Staff will review the process of the importance of when and how to use the Notifying the Emergency Contact Form. It will be used immediately and or within 12 hours after a resident decides to end their residency in program or does not return when expected. The staff will be required to make at least one attempt to notify the client's emergency contact and to document on the form.
In addition, file inspections will be conducted at various times during the year to increase accountability and to assure that the said process is being followed.
This will be monitored by Gena Pina Garcia on a monthly basis by reviewing files regularly.
It is at C37W6701 YMCA of Reading and Berks County |
§ 717.30(d)(2) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen in addition to the fire extinguishers required under paragraph (1) . The extinguisher in the kitchen must be located near an exit and away from the cooking area.
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Observations
Based on a review of the fire extinguishers located throughout that property, the recovery house failed to have fire extinguishers located in the kitchen.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Implementation of Changes are as follows:
As of 03/25/2024 A fire extinguisher has been put up and added by the refrigerator on the wall in the kitchen on the 6th floor rear and will remain there.
This will be monitored by Gena Pina Garcia on a weekly basis to ensure that this does not reoccur. |