INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection T5O16701 Joy of Living 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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§ 717.31(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.
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Observations
Based on review of the resident records the license failed to file an unusual incident with the Department within 3 business days following an unusual incident involving an event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel in 2 out of 6 reviewed records.
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Plan of Correction
Joy of Living has revised the internal policies to reinforce the three business day reporting requirement.
All new staff will be trained within 30 days of hire on the DDAP regulation 717.31 to ensure clear understanding of reporting requirements.
The Program Manager will be assigned the role of compliance officer. Together with the House Manager, the PM will oversee incident reporting and confirm all reports are filed on time.
Administration will develop a checklist for incident reporting to ensure adherence to all required steps. The recovery house manager will communicate the updated policies to staff at the next scheduled staff meeting on 3/20/2025.
The House Manager and Program Manager will conduct weekly compliance audits for the next 60 days and will review these findings to address any defects or challenges during monthly staff meetings. |