INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on February 21, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection XTRT6701 Easy Does It, Inc 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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§ 717.22(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 client 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 3 out of 13 records .
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The recovery house has reviewed the admission process and implemented safeguards into the process from beginning of residency to the time of discharge. Each staff member involved in the intake and discharge process will review their assigned chart sections to ensure that all items are present in the chart and complete. Staff will continue to use the index as a guide to necessary documentation that should be in the chart and at what location. The House Manager (Director of Operations) will monitor that charts are complete throughout residency, via routine audits. The Admissions Coordinator will ensure that all beginning of residency documents are present at the time of admission and that they are completed before moving to the next part of the admission process. This deficiency was corrected on 2/28/2024. |
§ 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 4 out of 13 resident 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
The House Manager updated the policies relating to Notification to family or emergency contact. The House Manager for the licensed recovery house (EDI's Director of Operations) is responsible for achieving and maintaining compliance with the requirement. The House Manager will review this policy with all staff through individual and group supervision. In all future instances when emergency notification is required, the House Manager will ensure that the recovery specialist who has worked directly with the resident will attempt the emergency contact and document the resident's file with a note. This deficiency was corrected on 2/28/2024 and will continue to be monitored for compliance. |
§ 717.29(e)(7) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection the recovery house failed to maintain maintain the women's handicap shower in a clean and sanitary manner.
Findings: The womens handicap shower had a substance caked on the floor.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The recovery house has completed the necessary changes for this deficiency related to physical plant standards in bathrooms involving a substance found on the women's bathroom floor. The handicap shower area has been thoroughly cleaned. Evidence of these changes was presented to the auditor via email. This deficiency was corrected on 3/1/2024. |
§ 717.29(f)(4) LICENSURE Physical plant standards - Kitchens
§ 717.29. Physical plant standards.
(f) Kitchens. The licensee shall:
(4) Ensure that food items are stored off the floor.
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Observations
Based on the physical plant inspection the recovery house failed to ensure that all food items are stored off the floor.
Findings: The recovery hosue had food in milk crates on the floor.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The recovery house has completed the necessary changes for this deficiency related to physical plant standards in kitchens involving food items and them being stored off the floor. All food and food related items are stored off the floor and in compliance with DDAP guidelines. Evidence of these changes was presented to the auditor via email. This deficiency was corrected on 2/26/2024 and will continue to be monitored for compliance. |
§ 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 the physical plant inspection the recovery house failed to have 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.
Findings: There was no ABC rating fire extinguisher located in the kitchen.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The recovery house has completed the necessary changes for this deficiency related to safety and emergency procedures involving fire extinguishers. There are now ABC rated fire extinguishers, as well as K rated fire extinguishers, in both kitchens within EDI. Evidence of these changes was presented to the auditor via email. This deficiency was corrected on 2/26/2024. |