INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 01, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, WQH06701 Merakey Fresh Start Foundation 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 mechanism to collect feedback on completed training in all staff records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Merakey Fresh Start Foundation will utilize its internal electronic training platform, myLearning - LMS (Learning Management System), to collect feedback on completed trainings from all staff members.
At the completion of each training, employees will have the opportunity to share their feedback with Merakey's training department, which is reviewed with the Executive Director on a monthly basis. |
§ 717.22(b)(5) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
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Observations
Based on a review of resident records, the recovery house failed to disclose and have resident sign the notification of emergency form within 24 hours of arrival which identifies situations when recovery house staff may notify the resident ' s emergency contact in four of seven resident records. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Merakey Fresh Start Foundation's emergency contact forms were updated to include a signature line stating that all residents must provide an emergency contact within 24 hours of arrival. In the event that a resident does not have an emergency contact, we will notify their Outpatient Therapist in these situations, since an active release for the Outpatient Therapist is mandatory for funding in Office of Addiction Services programs. |