INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection MSPO6701 Safe Haven 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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§ 717.21(a) LICENSURE Resident Roster
§ 717.21. Resident roster.
(a) The licensee shall maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
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Observations
Based on review of the resident records the recovery house failed to have a resident roster.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Resident roster has been created (Excel file) listed are the name, beginning of residency date and end of residency date. This roster shall be maintained by the prospective Director of the facility. The Director of Transitional Living is responsible for implementation of the corrective action. Action completed 05.28.2025. |
? 717.22(b) 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.
(2) Resident orientation to the drug and alcohol recovery house which must include all of the following:
(i) Drug and alcohol recovery house rules, including a method to record residents ' expected return time to the drug and alcohol recovery house.
(ii) Fee schedule including any lease agreement.
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
(iv) Financial policies and procedures.
(v) The location of posted emergency procedures and contact information for the house manager and the Department.
(vi) Medication control and self-administration policies.
(3) Basic personal data including:
(i) Name.
(ii) Birth date.
(iii) Demographic information.
(iv) Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker and other medical conditions that the resident chooses to have in the house record.
(v) Drug and alcohol history.
(vi) Medical contact information.
(vii) Emergency contact.
(4) Consent to residency.
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
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Observations
Based on review of resident records the recovery house failed to collect full basic personal date.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All current resident records have been reviewed by the prospective Director. The missing "drug and alcohol history" and "Emergency medical contact" sections have been completed. It is the responsibility of the prospective Director to monitor and correct any missing information within the resident records in a timely fashion. Corrective action to be completed 06.06.25. |
§ 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.
In 1 out of 3 resident discharge records 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
Each prospective Director is responsible to notify or attempt to notify at least once the resident's emergency contact within 12 hours of the resident's decision to end residency or does not return to the recovery house. Each prospective Director is responsible to fully fill out the End of Residency Form and place into the Resident's record in a timely fashion. Corrective action to be completed by 06.06.25 |