INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 7KXF6701 Step by Step Sober Living, Inc 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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? 717.15(c) LICENSURE House Manager
§ 717.15. House Manager.
(c) The house manager shall complete at least 6 hours of training in one or more of the following areas within 6 months of becoming house manager, and annually thereafter:
(1) Fiscal policy.
(2) Administration.
(3) Program planning.
(4) Quality assurance.
(5) Program licensure.
(6) Personnel management.
(7) Confidentiality.
(8) Ethics.
(9) Trends in drug use and misuse.
(10) Developmental psychology.
(11) Interaction of addiction and mental illness.
(12) Cultural awareness.
(13) Sexual harassment.
(14) Relapse prevention.
(15) Substance use disorders.
(16) Peer support or mutual aid groups.
(17) Best practices for medication control and self-administration.
(18) Infection control.
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Observations
Based on a review of staff records, the recovery house failed to complete House Manager training for the required annual 6 hours training for house manager using a department approved curriculum training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager
Step by Step has implemented the procedures according to 717.15. The following plan of correction and will have it implemented by 1/30/2025.
The House Manager will complete the training for the required annual 6 hours using the DDAP approved curriculum of training. And a copy will be available in the House Managers file.
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§ 717.18(c)(1) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(1) Cardiopulmonary resuscitation (CPR) certification.
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Observations
Based on a review of staff records, the recovery house failed to complete House Manager training for CPR certification for house manager using a department approved curriculum training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
CPR Training
Step by Step has implemented the procedure according to 717.18. The following plan of correction will have been implemented by 1/30/2025.
The House Mananger will complete the training for CPR certification using the DDAPpproved curriculum . And a copy of the certificate will be kept in the current hosemanagers file. This will be reviewed by the House manager as well as the program director to ensure that the the sais process is completed by said time and will continue to do so with any change of management. |
§ 717.18(c)(2) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(2) First aid training, including training on overdose reversal medication.
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Observations
Based on a review of staff records, the recovery house failed to complete House Manager training for First aid training, including on overdose reversal medication for house manager using a department approved curriculum training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Training 717.18
Training First Aid and overdose reversal medication:
Plan of Correction:
Step by Step has implemented the procedure according to 717.18. The following plan of corrections have been implemented on 1/30/2025.
The House Manager will complete training for first aid and overdose reversal medication using department approved curriculum. A copy of certificate will be kept in the house manager file.
This will be reviewed by the House Manager to ensure that this process is happening as expected.
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§ 717.18(c)(3) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on a review of staff records, the recovery house failed to complete House Manager training for HIV/AIDS, TB/STD for house manager using a department approved curriculum training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Training 717.18 (c)
In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer: (3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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§ 717.18(c)(4) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
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Observations
Based on a review of staff records, the recovery house failed to complete House Manager training for Fire Safety for house manager using a department approved curriculum training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Training Fire prevention and emergency preparedness, including fire extinguisher:
Plan of Correction:
Step by Step has implemented the procedure according to 717.18. The following plan of corrections have been implemented on 1/30/2025.
The House Manager will complete training for Fire Prevention and emergency preparedness, including fire extinguisher using department approved curriculum. A copy of certificate will be kept in the house manager file.
This will be reviewed by the House Manager to ensure that this process is happening as expected.
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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 provided any discharge records in order to determine if written notification was given to the resident to end residency, if an opportunity to request the licensee reconsider to end residency was provided or if resident decided to end residency without providing a reason to the licensee.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Notification of decision to end residency:
Plan of Correction:
Step by Step has implemented the procedure according to 717.23. The following plan of corrections have been implemented on 12/1/2024.
A written notification will be given to the resident to end residency with an opportunity to request the licensee reconsider to end residency. Documentation of the form of notification will be noted in resident file.
This will be reviewed by the House Manager biweekly to ensure that this process is happening as expected.
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§ 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 3 out of 3 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
Notification of decision to end residency:
Plan of Correction:
Step by Step has implemented the procedure according to 717.23. The following plan of corrections have been implemented on 12/1/2024.
A written notification will be given to the resident to end residency with an opportunity to request the licensee reconsider to end residency. Documentation of the form of notification will be noted in resident file.
This will be reviewed by the House Manager biweekly to ensure that this process is happening as expected. |