INITIAL COMMENTS
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This report is a result of an renewal on-site licensure inspection conducted on March 28, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, QC556701 Emilie House 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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§ 717.19(b) LICENSURE Resident Rights
§ 717.19. Resident rights.
(b) The licensee shall obtain written acknowledgement by residents that they have received notice of their rights.
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Observations
Based on a review of resident records, the recovery house failed to obtain written acknowledgment that the resident has received notice of their rights.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager has added the approved Residents Rights Form to the intake packet for residents to be signed upon admission and has implemented the use of a checklist of required completed forms to be completed by the House Manager within 24 hours of intake as of 4/4/23. |
§ 717.22(b)(2)(iv) 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:
(iv) Financial policies and procedures.
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Observations
Based on a review of resident records, the recovery house failed to 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:
(iv) Financial policies and procedures.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager has added the approved Resident Orientation Form that incudes financial policies and procedures to the intake packet for residents to be signed upon admission and has implemented the use of a checklist of required completed forms to be completed by the House Manager within 24 hours of intake as of 4/4/23. |
§ 717.22(b)(3)(vii) 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:
(3) Basic personal data including:
(vii) Emergency contact.
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Observations
Based on a review of resident records, the recovery house failed to obtain emergency contact information from the resident.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager has added a supplementary Emergency Contact Form to the Intake pack for residents to be signed upon admission and has implemented the use of a checklist of required completed forms to be completed by the House Manager within 24 hours of intake as of 4/4/23. |
§ 717.22(b)(4) 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:
(4) Consent to residency.
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Observations
Based on a review of resident records, the recovery house failed to obtain a signed consent to residency within 24 hours of arrival.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager has added the approved Consent to Residency Form to the intake packet for residents to be signed upon admission and has implemented the use of a checklist of required completed forms to be completed by the House Manager within 24 hours of intake as of 4/4/23. |
§ 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 notify the resident in writing of a decision to end residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager has created and implemented the use of discharge paperwork which includes a written decision to end residency, a timeframe for ending residency, the ability to request reconsideration within the time frame, and a line that acknowledges if the resident chose to end residency as of 4/4/23. |
§ 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 (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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager has created and implemented a plan to document the notification of emergency contact or family member within 12 hours of a resident's discharge as of 4/4/23. |
§ 717.30(b)(1) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(1) Ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
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Observations
Based on an on site, physical plant inspection, the recovery house failed to ensure that the second exit was unobstructed on the second floor of the recovery house.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager ensured that the second exit on the second floor of the recovery house was unobstructed by rearranging furniture, and implemented a policy that the exit would not be obstructed by any residents property at any time for any reason. |