INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 24, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection C7I56701 Restorative Roots 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.
|
Plan of Correction
|
§ 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.
|
Observations
Based on review of resident records it was determined that the licensee failed to complete have documentation signed within 24 hours, including
(1)Disclosure to the resident of criteria for beginning and ending residency.
|
Plan of Correction
Upon notification of this deficiency, Restorative Roots reviewed all admission and orientation documents to ensure compliance with requirements for obtaining resident signatures within 24 hours.
All required forms?including the disclosure of residency criteria?have been updated, standardized, and transitioned into DigiSign to ensure timely completion and electronic timestamping. This system prevents delays, ensures all required fields are completed, and automatically documents the date and time of signature.
Corrective Action Completed:
- All admission and residency-related forms have been updated and moved into DigiSign.
- All staff have been trained on the revised forms and the requirement to obtain signatures within 24 hours of admission.
- The House Manager will verify completed documents during each admission and file them immediately in the resident's electronic record.
Systemic Prevention:
To prevent recurrence, the owner(s) of Restorative Roots will review all new resident files within 24 hours of admission to ensure compliance. Any missing documentation will be addressed immediately. Quarterly audits will also be performed to ensure ongoing adherence.
Restorative Roots considers this deficiency corrected as of the date of this submission. |
§ 717.22(b)(2)(ii) 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:
(ii) Fee schedule including any lease agreement.
|
Observations
Based on review of the resident records, the recovery house failed to have 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:
(ii) Fee schedule including any lease agreement.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
During the licensing review, it was identified that Restorative Roots did not have a formal fee schedule or lease agreement included in the resident orientation packet. This occurred because the program had historically been fully funded through the local SCA, and fee-based documentation had not been required for residents.
To correct this, Restorative Roots has developed a comprehensive Fee Schedule and Lease Agreement form. This form clearly outlines all funding pathways, including SCA-funded placement, Opioid Settlement Grant funding, and Self-Pay obligations. It also details financial responsibilities in the event that funding lapses or is discontinued.
The revised form has been added to the intake packet on 11/18/2025 and incorporated into DigiSign to ensure accurate electronic timestamping, completion, and proper record retention.
Corrective Action Completed:
- A new Fee Schedule and Lease Agreement form has been created and implemented.
- The intake packet and orientation documents have been updated to include the new form.
- The form has been uploaded into DigiSign for completion during all admissions.
- The House Manager has been trained on the new documentation and procedures.
Systemic Prevention:
The House Manager will ensure that all residents review and sign the Fee Schedule and Lease Agreement within 24 hours of application or admission. The Program Director will conduct quarterly audits of resident files to confirm ongoing compliance and address any discrepancies immediately.
Restorative Roots considers this deficiency corrected as of the date of this submission. Everything has been corrected as of 11/18/25 |
§ 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.
|
Observations
Based on review of the resident records, the recovery house failed to have documents signed within 24 hours of arrival.
(4) Consent to residency.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
During the licensing review, it was identified that Restorative Roots did not have a formal Consent to Residency included in the admission documentation. This form has now been created to ensure that all residents acknowledge and agree to program expectations, rights, and responsibilities prior to entering the recovery house.
The Consent to Residency form has been added to the admission packet as of 11/18/25 and incorporated into DigiSign to ensure timely completion, electronic timestamping, and proper documentation.
Corrective Action Completed:
- A new Consent to Residency form has been created.
- The form has been added to the intake and orientation packet.
- The form has been uploaded into DigiSign for digital completion and secure recordkeeping.
- Staff, including the House Manager, have been trained on the requirement to obtain this consent during every admission.
Systemic Prevention:
The House Manager will ensure all residents review and sign the Consent to Residency form within 24 hours of admission. The Program Director will conduct quarterly compliance audits of resident files to ensure documentation is consistently completed and properly maintained.
Restorative Roots considers this deficiency corrected as of the date of this submission. Everything has been corrected as of 11/18/25 |
§ 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.
|
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 (b) 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.
These findings were reviewed with the recovery house staff during the licensing process
|
Plan of Correction
During licensing review, it was identified that although Restorative Roots did notify emergency contacts as required, the notification was not consistently or properly documented in the resident record. To correct this, Restorative Roots has created a standardized Emergency Contact Notification Form to ensure detailed, accurate, and timely documentation of all required notifications.
This new form has been added to DigiSign on Everything has been corrected as of 11/18/25 with mandatory completion fields to prevent omissions and ensure consistency. Staff have been retrained on proper documentation procedures, including the requirement to record the date, time, method of contact, and the name of the person notified.
In instances where a resident refuses to provide emergency contact information, staff will now document the phrase "Refused to provide," rather than using "N/A," to maintain clarity and compliance.
Corrective Action Completed:
- A new Emergency Contact Notification Form has been created and implemented.
- The form has been added to DigiSign with mandatory fields for complete documentation.
- Staff have been retrained on emergency contact requirements and proper documentation standards.
- Procedures were updated to document "Refused to provide" when a resident declines to list an emergency contact.
Systemic Prevention:
The House Manager will review all discharge and AWOL files within 24 hours to confirm that emergency contact notification is properly documented. The Program Director will perform quarterly file audits to ensure continued compliance and address any discrepancies immediately.
Restorative Roots considers this deficiency corrected as of the date of this submission. Everything has been corrected as of 11/18/25 |