INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection ,O0RC6701 Best Of Service CC 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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§ 717.10 LICENSURE 0149-Right to enter and inspect
§ 717.10. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit and inspect a drug and alcohol recovery house licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the drug and alcohol recovery house and its residents.
(c) The authorized Department representative has the right to interview residents as part of the visitation and inspection process.
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Observations
Based on the initial scheduled date for the renewal DDAP staff was not able to enter, visit and inspect a drug and alcohol recovery house on licensed or applying for a license under this chapter on March 13, 2026.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The plan of correction is imp[lemented on April 28 2026 the House Manager takes full responsibility also is house managers responsibility to have all doors able to be entered and exited to ensure this deficiency does not recur House manager will pre check to make sure that all entrances and exits are available so this deficiency doesnt recur in moving forward . |
? 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 discussion with the House Manager, the 6 hours of annual training was not taken.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
The House Manager will complete the 6 hour annual HOUSE MANAGER training by 5 /30 /2026.FOR this to occur again the house manager will set a reminder that the 6 hour annual training will be completed prior to next renewal.THE house Manager is responsible for this plan of correction. |
§ 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
House Manager has implemented plan of correction on 4 28 2026 also takes full responsibility for failing to have written acknowledgement by residents that they have received their notice of rights to ensure this does not recur House manager will recheck all documents to be ahead and not failing at this nor allowing this to recur |
§ 717.21(a) LICENSURE Resident Roster
§ 717.21. Resident roster.
(a) The licensee shall maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
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Observations
Based on review of the submitted documents and onsite renewal the recovery house failed to have a resident roster.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager has implemented the resident roster on April 27 2026 .The date of admission,discharge will be listed for the years.The House Manager is responsible for ensuring this does not happen again by maintain the sheet correctly. |
§ 717.22(b)(1) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
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Observations
Based on review of the resident records the licensee failed to inform residents of criteria of beginning and ending of residency which must be signed by the resident, within 24 hours of arrival. This occurred in five out of five records.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
House manager has implemented the plan of correction on April 1 2026 by ensuring going forward, all documentation that is needed will be signed within 24 Hours of the resident arrival. This includes the beginning and ending of residency .The house Manager is responsible for ensuring this does not happen. |
§ 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 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.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
House manager has implemented the plan of correction on April 1, 2026 by ensuring going forward ,all documentation that is needed will be signed within 24 hours of resident arrival,The House manager is responsible for ensuring this does not happen again. |
§ 717.22(b)(3)(vii) 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:
(3) Basic personal data including:
(vii) Emergency contact.
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Observations
Based on review of resident records the licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival: emergency contact information was not collected.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager has implemented the plan of correction on April 1, 2026 by ensuring going forward that emergency contact information is collected within 24 hours of arrival.In the case of a resident declining to provide the emergency contact form .The house manageris responsible for ensuring this does not happen again. |
§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
Based on a review of resident records, the recovery house failed to provide a written notification to the resident stating the decision to end residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In the event of a unsuccessful discharge, the following has been implemented on 4/27/26, the resident will receive a written notification of reason for discharge, date of discharge and every attempt will be made to give the resident the ability to sign and ask for reconsideration. In the event that the resident refuses to sign it will state on the form.The house manager will ensure this does not happen again by reviewing records in a timely manner to ensure that the required form is in the resident record. |
§ 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 make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) 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.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
The plan of correction was implemented on April 27, 2026, and going forward the House Manager is responsible for making the contact to the family member or emergency contact. Also, in the event of a death, hospitalization and unsuccessful discharge, failure to return, the emergency contact form with date and time of contact. It is the House Managers responsibility to ensure that this deficiency does not occur again by reviewing discharges immediately, the documentation of the emergency contact was made is written in the resident record. |
§ 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.
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Observations
Based physical plant inspection the recovery house 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: trash in yard.
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Plan of Correction
The plan of correction was implemented on April 27 2026 and it is the house managers responsibility to ensure that the ground ,interior,exterior kept clean by checking that chores are being completed weekly.It is the house managers responsibility to ensure that chores are being completed so the deficiency does not occur again. |