INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection EEEB6701 Rainey's Lighthouse 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 resident records, the recovery house failed to provide a written notification to the resident stating the decision to end residency.
In 1 out of 2 unsuccessful resident discharge files the recovery house failed to provide a written notification to the resident stating the decision to end residency.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
We have implemented a written notification to end residency form to provide to a resident when there is a decision to end residency. This will be provided to the resident by the house manager and/or business manager. The use of this form was effective 5/8/24. |
§ 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.
In 2 out of 2 unsuccessful resident discharge 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
We have added space on the written notification to end residency form to include a space for the for the date and time when notification to an emergency contact was attempted and/or made. provide to a resident when there is a decision to end residency. This will be updated and recorded by the house manager and/or business manager. The use of this form and the proper recording of emergency contact notification was effective 5/8/24. |