INITIAL COMMENTS
|
This report is a result of an off-site complaint investigation conducted between November 30, 2023 - December 12, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the off-site complaint investigation, MERAKEY FRESH START FOUNDATION 2067 - K59I6701 was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertain to the facility.
|
Plan of Correction
|
§ 717.26 LICENSURE Complaint management
§ 717.26. Complaint management.
The licensee shall develop and implement written policies and procedures for managing complaints from residents, family members and community members, which must include procedures for informing residents, family members and community members of the complaint process, including the ability to file a complaint with the Department.
|
Observations
Following an offsite investigation, which involved interviews with staff, resident, and the local SCA, it has been determined that the recovery house failed to deliver a decision in writing within 48 hours of the complaint and neglected to furnish the resident with a copy of the final decision.
|
Plan of Correction
Merakey Fresh Start management will have a group supervision meeting with all staff to review our compliant management policy. All staff will have an opportunity to ask questions and will sign a supervision note stating that they understand the policy and their responsibilities. This supervision note will be stored in their employee file for reference. In addition, all residents filing a complaint will be provided with a letter explaining Merakey Fresh Start's response and decision on how the complaint was addressed, and a copy of this letter will be stored in the client file for reference. |
§ 717.31(c)(4) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(4) An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
|
Observations
Following an offsite investigation, which involved interviews with staff, resident, and the local SCA, it has been determined that the recovery house failed notify the Department within three business days following an unusual incident involving the presence of police.
|
Plan of Correction
Merakey Fresh Start management will have a group supervision meeting with all staff to review the Unusual Incident policy and their responsibilities during these incidents. A signed copy of this supervision note will be added to each employee's file for reference. Merakey Fresh Start management will be responsible for making sure that DDAP is formally notified of unusual incidents and that the reports are submitted in the appropriate timeframe moving forward. |