INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection ME906701 Phoenix Recovery House 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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§ 717.6(e) LICENSURE Application and renewal
§ 717.6. Application and renewal.
(e) The Department will not issue or renew a license until the applicant or licensee has completed and submitted all forms, documents, and fees required under this section.
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Observations
During the annual licensing renewal, the facility failed to provide to the department all requested forms and documents as required.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
effective immediately, Forms will be provided 2 weeks prior to annual renewal inspection from the house manager. Form will be uploaded to the sharefile |
? 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 the house manager ' s personal record, the facility failed to provide documentation for the house manager completing at least 6 hours of training for the 2025 training year.
Staff #1 was hired as the house manager on September 26, 2024, and was still in this position at the time of the inspection. There was no documentation of the annual training required provided.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Effective immediately, all future trainings will be completed through approved sites by the house manager, Trainings will be uploaded to the the licensing specialist Sharefile.
All training will be completed through the DDAP website.
A minimum of 6 house of training will be completed by the end of 2026 |
§ 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 facility failed to provide documentation for all staff persons and volunteers to complete Cardiopulmonary resuscitation (CPR) certification training using a department approved curriculum.
Staff #1 was hired as the house manager on September 26, 2024, and was still in this position at the time of the inspection. CPR certification was not provided during the inspection process.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
CPR/AED certification was completed 9/25/2026 by Project manager through the American Red Cross.
Certification will be present at next house inspection.
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§ 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 facility failed to provide documentation for all staff persons and volunteers to complete first aid training, including training on overdose reversal medication training using a department approved curriculum within 90 days of hire.
Staff #1 was hired as the house manager on September 26, 2024, and was still in this position at the time of the inspection. There was no documentation of first aid training, including training on overdose reversal medication being completed within 90 days of hire.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Effective immediately, all future trainings will be completed through approved sites by the house manager, Trainings will be uploaded to the the licensing specialist Sharefile.
House manager completed first aid and overdose training 9/15/2025 through the American red cross
Certificate of completion will be present at the next house inspection. |
§ 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 facility failed to provide documentation of all staff persons and volunteers to complete HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum within 90 days of hire.
Staff #1 was hired as the business manager on September 26, 2024, and was still in this position at the time of the inspection. There was no documentation on HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum that was completed.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
HIV certificate was completed by house manager on 9/23/2026.
Certification will be present at next inspection. |
§ 717.22(b)(1) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
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Observations
Based on seven resident records reviewed, the facility failed to provide documentation, signed by the resident, disclosing the criteria for beginning and ending residency.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
Effective 9/15/2026 All Residents are required to do an exit form prior to leaving. If the resident does not return to the house, the exit form will be documented accordingly by the recovery house staff. |
§ 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 three of three applicable discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected.
Resident #5 was admitted on July 18, 2026, and discharged July 28, 2026. There was no notification to the emergency contact provided in the resident record.
Resident #6 was admitted on May 18, 2026, and discharged August 1, 2026. There was no notification to the emergency contact provided in the resident record.
Resident #7 was admitted on January 7, 2026, and discharged July 2026. There was no notification to the emergency contact provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Effective 9/15/26 The Facility will require all residents to have an emergency contact phone number in case of an emergency. Emergency contact will be notified the day the resident leaves the facility by the recovery house staff. The resident file will be documented. |