INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on 04/28/2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 517010 Gibson Foundations 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(b) LICENSURE Training
§ 717.18. Training.
(b) The licensee shall conduct and document an evaluation of the training plan annually.
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Observations
Based on a review of staff records, the recovery house failed to have a complete staff record. The recovery house failed to conduct and document an evaluation of the training plan annually in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Staff records will be documented according to section 717 by the site manager during their shift, which will include dates and duration of training, a training plan and evaluation of staff after their training. A newly hired staff will attend training within 90 days of hire and according to the job description, managers will also attend training within 6 months after the license inspection. All documents will be kept in an orderly file, by the manager for easy access. The director will periodically inspect all documents and ensure that trainings are done in the time frame assigned. |
§ 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 have a complete client record. The recovery house failed to obtain written acknowledgement by residents that they have received notice of their rights in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The site manager will check all resident's records for discrepancies, including the resident's handbook, which will include Residents Rights and their acknowledgement signature that they have received a copy. Resident's records will also include, consent, emergency contact information, discharge and follow up forms. Each staff person who does intake will ensure that the resident will be given a copy of their rights and sign a form to be kept in their records. The site manager will check all resident's files to make sure that the proper forms including discharge and follow up forms. The program director will conduct site visits and file inspections monthly. |