INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on April 28, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 517019 - Mercy Hospice was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing. 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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§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of staff records, the recovery house failed to have a complete staff record. The recovery house failed to have a mechanism to collect feedback on completed training in four of four staff records.
Staff # 101 was hired on May 05, 2022. Feedback mechanism form not found in the employee record.
Staff # 102 was hired on May 02, 2022. Feedback mechanism form not found in the employee record.
Staff # 103 was hired on June 21, 2022. Feedback mechanism form not found in the employee record.
Staff # 104 was hired on September 02, 2022. Feedback mechanism form not found in the employee record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Mercy Hospice will require all staff members and volunteers to complete a training feedback form within 48 hours. The program manager will assume responsibility for distributing training feedback forms to each staff member upon completion of training. The program manager will ensure that all training feedback forms are completed in placed in each staff members' record. |
§ 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 have resident sign notification to family member or emergency contact from in four of seven records.
Client # 104 was admitted on January 30, 2023 and discharged on 04/19/2023. Notification to family member or emergency contact form not found in the client record.
Client # 105 was admitted on March 30, 2023 and discharged on 04/09/2023. Notification to family member or emergency contact form not found in the client record.
Client # 106 was admitted on March 23, 2023 and discharged on 04/17/2023. Notification to family member or emergency contact form not found in the client record.
Client # 107 was admitted and discharged on March 22, 2023. Notification to family member or emergency contact form not found in the client record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Mercy Hospice will have all residents sign an Emergency Contact Form at the time of admission into the program. The Social Services Supervisor will check all newly admitted resident records within 24 hours to ensure the Emergency Contact Form is completed and placed in the resident's record.
Case Managment will be responsible for notifying resident's emergency contact when a resident is discharged within 12 hours. Case Managment will also document this contact in the Resident's Discharge Form within 12 hours.
The Social Services Supervisor will follow-up within 24 hours to ensure that residents emergency contacts have been notified, documented in the Discharge Form and placed in the resident's record. |