INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on January 30, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection MDHR6701 Next Step Recovery House 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 review of the resident records the recovery house failed to 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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
1. Resident roster on excel created which has move in date and date of termination.
2. Phone log sheet created to record all contact made with residents emergency contact/ family.
3. Letter/ form created to document termination of lease and permission to contact emergency person or family. Both lessee and lessor will sign and date.
These procedures went into effect 2-1-2024 implemented by house mng/ owner Michael Mullen. Michael will be responsible for all documentation in future and training. |
§ 717.30(b)(2) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(2) Maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
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Observations
Based on the physical plant inspection the recovery house failed to maintain a minimum of two unobstructed exits.
Findings:
The first fire exit door was blocked with boxes.
The second fire exit door was locked.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
1. All locks were removed from two doors on second floor leading to attic.
2. Boxes were removed from in front of door.
3. Sign placed on both doors- EMERGENCY EXIT DO NOT BLOCK OR LOCK DOOR.
Owner/ house mng Michael Mullen performed correction on 2-1-2024. Michael will be responsible to monitor and all training in future if needed. |