INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection LZ136701 Empower Works 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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§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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Observations
Based on review of the staff records the recovery house failed to provide an assessment of completed trainings
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of 6/23/25 it is the responsibility of the house manager to ensure all required trainings that are completed will be accompanied with a brief evaluation of the training. This will be monitored by the house manager to ensure that this is being completed. |
§ 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 review of the staff records the recovery house failed to provide proof of CPR training 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
All updated CPR training cards will be kept in the personnel files. Any new hires will complete the CPR training within 90 days of hire. This will be checked by the house manager. Any missing CPR trainings will be completed by July 9, 2025. A copy of the completed training will be kept in the personnel file. |
§ 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 review of the staff records the recovery house failed to provide proof of first aid training, including training on overdose reversal medication to be completed within 90 days of becoming and employee or volunteer.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
First Aid training will be completed immediately, and a copy of the card will be maintained in the personnel file. This will be completed by July 9, 2025. |
§ 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 review of the staff records the recovery house failed to provide proof of HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum completed within 90 days of becoming an employee or volunteer.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
HIV/AID, Tuberculosis and sexually transmitted disease training will be completed by July 9, 2025. A copy of the training certificate or other proof of training will be sent to the licensing specialist by July 9, 2025. A copy of the completed training will be kept in the personnel file. |
§ 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 review of the resident records the recovery house failed to have written acknowledgement by residents that they have 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
Acknowledgement of resident rights will be signed at time of admission. The house manager will ensure that this citation does not reoccur by checking records weekly to ensure that all documentation is in the resident record. This was discussed with house manager on 6/22/25. |
§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
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Observations
Based on review of resident records the recovery house failed to have resident consent, emergency contact information, and beginning and ending of residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager will ensure that this citation does not reoccur by checking records weekly to ensure that all regulatory documentation is in the resident record. This will begin on June 23, 2025. |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
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Observations
Based on a review of the fire extinguishers located throughout that property, the recovery house failed to have fire extinguishers inspected and approved annually by the local fire department or fire extinguisher company.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
COMPLETED: All fire extinguishers were inspected on 6/17/25.
The House Manager will ensure that all fire extinguishers are inspected annually. |
§ 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
Based on review of the resident records the licensee failed to file an unusual incident with the Department within 3 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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All unusual incidents shall be reported to DDAP with in 3 days of the incident occurring. This will be reviewed with house managers and monitored whenever there is need for ambulance, police, or fire department. The unusual incident was reported on June 18, 2025. |