INITIAL COMMENTS
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This report is a result of an renewal on-site licensure inspection conducted on May 21, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 7BXY6701 Friendship First was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
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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 a review of staff records it was determined the recovery house failed to collect feedback on completed training. These findings were reviewed with recovery house staff during the renewal inspection process.
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Plan of Correction
Homeowner and Recovery House manager will have a signed training feedback submitted for official records by Dec 31 of 2026 and each Dec 31 of subsequent years. |
§ 717.18(b) LICENSURE Training
§ 717.18. Training.
(b) The licensee shall conduct and document an evaluation of the training plan annually.
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Observations
Based on a review of staff records it was determined the recovery house failed to conduct and document an evaluation of the staff training plan annually. These findings were reviewed with recovery house staff during the renewal inspection process
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Plan of Correction
Recovery house will document and evaluate staff training annually by Dec 31 of calendar year. |
§ 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 a review of resident records, the recovery house failed to document at least one attempt to notify the 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. These findings were reviewed with recovery house staff during the renewal inspection process.
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Plan of Correction
Recovery house manager will notify emergency contact within 12 hours of dismissal or leaving of the house unless allegation of domestic abuse exist on the resident by the emergency contact. |
§ 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.
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Observations
Based on a review of the physical plant the recovery house failed to securely affix the secondary exit to the house. These findings were reviewed with recovery house staff during the renewal inspection process.
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Plan of Correction
Recovery manager connected a secondary exit to the house on the 2nd floor. Pictures were provided and approved of the ladder securely affix by Licensing Specialist. |