INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 8O256701 Step By Step LLC 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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§ 717.31(c)(4) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(4) An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
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Observations
The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving: An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
Based on review of the resident records the recovery house failed to notify the department when there was police contact.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The unusaul incident was filed on 10/21/2024 by house manager. Future unusaul incidents will be filed within 3 business days by house manager to prevent this from happenng again. |