INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, B3SE6701 Cold Bore Recovery 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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§ 717.15(b) LICENSURE House Manager
§ 717.15. House Manager.
(b) The licensee shall identify the house manager in the application submitted to the Department and shall notify the Department in writing any time the house manager changes within 30 days.
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Observations
Based on review of personnel records the recovery house failed to notify the Department in writing any time the house manager changes within 30 days.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.15(b) ? House Manager
The Department has updated its records to reflect the current House Manager. Going forward, the Executive Director or ops manager will notify the Department in writing within 30 days of any change in House Manager. The Operations Manager will maintain documentation of the notification in the facility's administrative records and verify compliance during annual licensing preparation.
Persons Responsible: Executive Director and House Manager
Date of Full Compliance: Currently in full compliance |
§ 717.22(b)(2)(i) 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:
(i) Drug and alcohol recovery house rules, including a method to record residents' expected return time to the drug and alcohol recovery house.
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Observations
Based on review of the resident records the recovery house failed to have signed documentation by the resident of orientation to recovery house within 24 hours notifying the resident of rules.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.22(b)(2)(i) ? Beginning of Residency
Effective June 22, 2026, the House Manager or designated admission staff will review the recovery house rules and the method for recording expected return times with each new resident and obtain the resident's signed acknowledgment within 24 hours of arrival.
The Operations Manager will train applicable staff on this requirement by June 26, 2026. The House Manager will review each new resident file within 24 hours of admission to confirm the signed documentation is complete. The Operations Manager will conduct monthly file reviews and provide corrective training when necessary to maintain ongoing compliance.
Persons Responsible: House Manager and Operations Manager
Date of Full Compliance: June 26, 2026 |
§ 717.30(b)(1) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(1) Ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
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Observations
Based on the physical plant inspection the licensee failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
### § 717.30(b)(1) ? Safety and Emergency Procedures: Exits
All items obstructing the identified stairway, hallway, or exit route were removed immediately. The House Manager will inspect all stairways, hallways, bedroom exits, and exterior exits during routine daily walkthroughs to ensure they remain unobstructed.
Staff and residents will be reminded that personal belongings, furniture, storage items, and other materials may not be placed in any exit route. The House Manager will verify compliance through monthly physical plant inspections and will ensure that any obstruction is corrected immediately.
**Persons Responsible:** House Manager and Operations Manager
**Date of Full Compliance:** June 3rd 2026
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§ 717.30(b)(5) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(5) Light interior exits and stairs at all times.
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Observations
Based on a review of the physical plant inspection the recovery house failed to have the interior exits and stairs lit at all times.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
### § 717.30(b)(5) ? Safety and Emergency Procedures: Exit Lighting
The lighting issue affecting the interior exits and stairways was corrected. The House Manager will check all interior exit and stairway lighting during routine daily walkthroughs to confirm that the areas remain properly lit at all times.
Any burned-out bulbs, damaged fixtures, or other lighting problems will be reported and corrected immediately. The Operations Manager will verify compliance during monthly physical plant inspections and maintain oversight of any needed repairs.
**Persons Responsible:** House Manager and Operations Manager
**Date of Full Compliance:** 6/3/2026
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