INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 6, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, O9716701 Fellowship House was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertain Recovery House licensing. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
|
Plan of Correction
|
§ 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.
|
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.
Findings: Four of seven staff did not attend the required trainings within 90 days.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Staff identified in need of infectious disease trainings have registered to complete the required training with DDAP for 9/23/26 & 9/24/26. House manager and Compliance/HR Director will ensure newly hired staff obtain the required trainings with the first 90 days of hire. |
§ 717.29(b)(1) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(1) Keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
|
Observations
Based on review of the physical plant inspection the recovery failed to keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
Findings: Bathroom lighs were not working. Lighting that was placed there was not safe.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Maintenance staff inspected the light fixture in question and bulbs are too old to be replaced; therefore, the light fixture will be removed and replaced with the ceiling patched. This repair will be completed by 8/21/2026. There is an existing ceiling light fixture that is in proper working order with a 60 watt bulb for proper lighting. The house monitors will report to the house manager if the lighting needs repair again. |
§ 717.30(b)(2) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(2) Maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
|
Observations
Based on review of the physical plant the recovery house failed to maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms.
Findings: The fire exit in bedroom 7 was obstructed.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
House staff removed the obstruction on 8/7/26 to the fire exit in bedroom 7. House Monitor will inspect daily during rounds to ensure it remains unobstructed. House monitors will report to the House manager any findings of future obstruction to the fire exit in bedroom 7. |