INITIAL COMMENTS
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This report is a result of an renewal on-site licensure inspection conducted on April 23, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, WDFY6701 R3 House LLC was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
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Plan of Correction
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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 it was found the recovery house failed to ensure all staff completed the following training using a Department approved curriculum - within 90 days of becoming an employee or volunteer:
Sexually Transmitted Diseases.
These findings were reviewed with the recovery house during the licensing process.
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Plan of Correction
1. R3 House will have (2) paid staff (Recovery Support Associates) complete the TMS STD training
2. R3 House will utilize the DDAP licensing alert "Minimum Content Requirements for Pennsylvania Department of Health
Approved Curriculum for Tuberculosis and Sexually Transmitted Disease" to create a training session for R3 House leadership and staff.
3. R3 Recovery Support Associates will provide the approved training to all new house leadership as part of orientation requirements. |
§ 717.22(b)(2)(i) 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:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(i) Drug and alcohol recovery house rules, including a method to record residents' expected return time to the drug and alcohol recovery house.
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Observations
Based on a review of resident records and a physical plant inspection it was found the recovery houes failed to include a method to record residents' expected return time to the drug and alcohol recovery house. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
R3 House will begin a sign in /sign out policy via an online app that will log a resident's entry and departure. These entries will be tracked by the administration and peer leaders. This app, in addition to the current R3 House policy and procedure which provides for bed checks and accountability measures, will verify R3 resident's where-abouts. |