INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection M9D06701 New Path Recovery Tmb Llc was found not to 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(c) LICENSURE House Manager
§ 717.15. House Manager.
(c) The house manager shall complete at least 6 hours of training in one or more of the following areas within 6 months of becoming house manager, and annually thereafter:
(1) Fiscal policy.
(2) Administration.
(3) Program planning.
(4) Quality assurance.
(5) Program licensure.
(6) Personnel management.
(7) Confidentiality.
(8) Ethics.
(9) Trends in drug use and misuse.
(10) Developmental psychology.
(11) Interaction of addiction and mental illness.
(12) Cultural awareness.
(13) Sexual harassment.
(14) Relapse prevention.
(15) Substance use disorders.
(16) Peer support or mutual aid groups.
(17) Best practices for medication control and self-administration.
(18) Infection control.
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Observations
Based on a review of the house manager ' s personal record, the facility failed to provide documentation of the house manager, completing at least 6 hours of training for the 2025 training year.Staff #1 was hired as the house manager on July 1, 2022, and was still in this position at the time of the inspection. There was only three hours of training documentation.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The facility will ensure the house manager completes the required minimum of six (6) hours of approved annual training in applicable subject areas outlined in § 717.15(c). The current house manager has been registered for department-approved trainings covering ethics, relapse prevention, and interaction of addiction and mental illness. All certificates of completion will be obtained and placed in the personnel file.
Systemic Prevention:
A training tracking log and annual training calendar will be implemented to monitor compliance for the house manager. The program director will review training documentation quarterly to ensure ongoing adherence to regulatory requirements.
Date of Compliance:
Full compliance will be achieved within 60 days and maintained annually thereafter.
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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 the house manager ' s personal record, the facility failed to provide documentation of the house manager completing a feedback form for the training completed for the 2025 training year in accordance with the facility policy and procedure manual. The policy and procedure indicate feedback will be collected and kept in personnel files.Staff #1 was hired as the house manager on July 1, 2022, and was still in this position at the time of the inspection. There was no documentation of feedback forms for completed training provided.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The facility will ensure written staff development procedures are fully implemented, including documentation of completed training feedback forms in personnel files. The house manager will complete the required training feedback documentation for the 2025 training year, and the completed form will be placed in the personnel file.
Systemic Prevention:
The facility will revise its staff development tracking process to include:
- A standardized training needs assessment
- A staff development plan for each employee/volunteer
- Required post-training feedback forms
- Quarterly administrative review of personnel files for completeness
These procedures will be incorporated into the policy and procedure manual and reviewed annually.
Date of Compliance:
Full compliance will be achieved within 60 days and monitored on an ongoing basis.
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§ 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 a review of staff records, the facility failed to provide documentation for all staff persons and volunteers to complete Cardiopulmonary resuscitation (CPR) certification training using a department approved curriculum.Staff #1 was hired as the house manager on July 1, 2022, and was still in this position at the time of the inspection. The CPR for this staff has expired.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The facility will ensure all staff persons and volunteers maintain current CPR certification using a department-approved curriculum. The house manager whose CPR certification expired has been scheduled for the next available certified CPR training. Updated certification documentation will be obtained and filed in the personnel record immediately upon completion.
Systemic Prevention:
The facility will implement a credential expiration tracking system with automated reminders issued 60 days prior to expiration. The program director will conduct quarterly personnel file audits to verify compliance.
Date of Compliance:
Compliance will be achieved within 14 days of the training date and maintained continuously.
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§ 717.29(e)(3) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120°F.
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Observations
Based on a physical plant inspection, the facility failed to keep the water temperature from exceeding 120 degrees Fahrenheit. The water temperature in the bathroom was read at 125 degrees Fahrenheit.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Mixing valves on the boilers require calibration or replacement, and ongoing temperature monitoring procedures were not formally scheduled.
Corrective Action:
The mixing valves on all boilers will be calibrated or replaced as needed to ensure proper and safe temperature regulation. Following completion of this work, Meenan Oil?who holds the preventative maintenance (PM) agreement for the boilers?will be contacted to inspect and confirm proper operation once boiler cleaning is completed, in accordance with the annual maintenance schedule.
Monitoring and Prevention:
A recurring reminder system will be implemented to check boiler temperatures twice per year to ensure continued compliance and safe operation. Responsibility for completing and documenting these temperature checks will be assigned to the House Manager.
Completion Date:
To be completed upon calibration/replacement of mixing valves and confirmation of inspection by Meenan Oil.
Responsible Party:
House Manager
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