INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on February 27, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection BGFT6701 Marty Mannor 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 the resident records the recovery house failed to provide the resident with written notification of a decision to end residency to include the reason and timeframe for ending residency.
Finding: In 2 out of 3 dischaged resident records there was no notification of ending residency given to the resident.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
Beginning 02/27/2024 and going forward we will correct the procedures surrounding an end to residency. When we as a board decide that we are going to end a residency, we shall make two (2) copies of the notice including the reason(s). One copy of the notice will be given to the resident, and the reason(s) will be explained and any questions will be answered. A second copy of the notice will be signed by the resident (if willing and available) and a board member. The signed copy of the notice will be filed with the rest of the residents' paperwork. |
§ 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 2 out of 3 discharged 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
As of 02/27/2024 and going forward we will ensure correct procedures are followed with regards to contacting the residents' emergency contact once residency has ended or when the resident does not return to the house. Within twelve(12) hours of the end of residency or if a resident does not return to the house when expected, we will make at least one (1) attempt to contact the emergency contact of the resident. If we suspect that a call to the emergency contact will, in any way, endanger the resident, we will make a note in the file as to the reason why we did not make contact. |