INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 3, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, ZGKN6701 The Women's Recovery Community Center 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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§ 717.23 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 provide a written notification to the resident stating the decision to end residency.
Findings:
In 4 out of 8 resident discharge files the recovery house failed to provide a written notification to the resident stating the decision to end residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The WRCC has a resident contract policy in place that gives the resident in writing, an opportunity to correct any violation of policy that does not require an immediate discharge from the program. Starting 5/23/24, a resident that is being discharged will receive notification in writing, the reason for discharge & the opportunity to correct the behavior prior to being asked to leave. This documentation will be filed in the resident record & will include the reason and time frame in which the resident is required to leave the premises. A copy of the document will be offered to the resident at time of discharge. If a resident leaves without giving notification, staff will document the circumstances on the resident discharge form and document the attempts made to notify the emergency contact. |
§ 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 8 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
Effective 5/23/2-24, The WRCC will make every effort to reach the emergency contact in the event the resident is discharged from the program or leaves for any reason. Staff will document attempts in the resident chart and if consent is revoked, staff will be sure to accurately document the circumstances surrounding the departure from the Women's Recovery Community Center. These policies are currently in place and staff have been reminded (5/23/2024) and will be sure to document these attempts in the resident record for review moving forward. |
§ 717.30(b)(5) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(5) Light interior exits and stairs at all times.
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Observations
Based on a review of the physical plant inspection the recovery house failed to have the interior exits and stairs lit at all times.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The WRCC will install lighting on steps that will meet DDAP standards. Repairs will be completed by 5/31/2024. |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
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Observations
Based on a review of the physical plant inspection the recovery house failed to have fire extinguishers inspected and approved annually by the local fire department or fire extinguisher company.
Findings: One fire extinguisher was not inspected.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
WRCC will have every fire extinguisher inspected annually, and hung as appropriate. To be completed by 5/24/2024. |