INITIAL COMMENTS
|
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, Y0E46701 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.
|
Plan of Correction
|
§ 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.
|
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.
On April 1, 2026, DDAP staff was not able to access the bedrooms at the recovery house to complete a full licensing inspection due to bedrooms being locked.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
On the original scheduled date of the inspection, I was unable to have transportation to bring me to the recovery house. As a result, the inspection was not able to be conducted, when the renewal did occur, we were unable to access bedrooms because they were locked to ensure that this does not recur again all the entrances of doors will be unlocked to enter any room as well exit , |
? 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.
|
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
|
Plan of Correction
I Jamie smith am willing to take the 6 hours of training when I can also i take responsibility for not already taken trainings I am taken the proper measures to be prompt to take trainings as well as not allow this citation to happen again as of April 1st I am correcting and have corrected this I fully apologize for my lack of responsibility. |
§ 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.
|
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.
|
Plan of Correction
I Jamie Smith fully take responsibility for citation On April 1st I was informed about the missing documents and immediately corrected the change so this does not occur again i will be prompt in utilizing all the proper procedures to not allow this to occur. |
§ 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.
|
Observations
Based on review of the docuemntation for the renewal the licnse failed to provid resident roster.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The house Manager has implemented the resident roster on April 27,2026.The name date of admission and discharge will be listed on resident roster .House Manager will be responsible for the updating of the form. to make or ensure this defieciency does not recur house manager will pre check weekly that the resident roster as well as documents needed are present and able for DDAP Staff to immediately obtain. |
§ 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.
|
Observations
Based on review of the resident records the licensee failed to inform residets of criteria of beginning and ending of residensy 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
|
Plan of Correction
The 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 residential arrival, House Manager is responsible for this deficiency also ensures this will not recur by keeping immediate weekly tabs on documents going forward as well as continue to do so to provide whats needed. |
§ 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.
|
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
|
Plan of Correction
The house manager has implemented the plan of correction on April1, 2026 by ensuring going forward ,all documentation that is needed will be signed within 24 Hours of the residential arrival. This includes orientation handbook, House Manager ensures this does not recur. |
§ 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.
|
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.
|
Plan of Correction
The house manager has implemented the plan of correction on April1 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 information it will be noted on emergency contact form, House Manager ensures 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.
|
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.
|
Plan of Correction
In the event of a unsuccessful discharge has been implemented on 4 27 26 , the resident will receive a written notification of the 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 will not happen again by viewing records at 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.
|
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.
In 3 out of 3 resident discharge records the recovery house failed to notify the emergency contact within 12 hours of residents departure
These findings were reviewed with the recovery house staff during the licensing process
|
Plan of Correction
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 will be notified within 12 hours of incident .the contact will be documented on the emergency contact form with date and time of contact. ensures that this deficiency does not occur again by reviewing discharges immediately |
§ 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 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, old food in refrigerator, house was not clean.
|
Plan of Correction
THE plan of correction was implemented on April 27, 2026 House Manager has the responsibility that the grounds ,interior kept clean by checking that chores are being completed weekly.It is House Manager responsibility that chores are being completed so the deficiency does not occur again. |
§ 717.29(e)(7) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
Based physical plant inspection the recovery house failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
This deficiency is the responsibility of chores House Manager take steps to ensure this does not recur will check Daily \Weekly to ensure all Bathrooms are in functional order and Clean /Sanitary at all times 04/24/2026 corrective action was completed . |
§ 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 the physical plant inspection 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. 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.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Plan of correction was implemented on April 27 ,2026 and it is the house managers responsibility to ensure that the bedroom containing the fire ladder is always unlocked and accessible in the case of emergency this was corrected by speaking to the resident and assisting him with storage for belongings and adding a door to the closet with a door that can be locked ,it is the house managers responsibility to ensure that this deficiency does not occur again by checking that bedrooms are not locked. |
§ 717.30(c)(1)(i) LICENSURE Safety and emergency procedures - Detectors
§ 717.30. Safety and emergency procedures.
(c) Smoke and carbon monoxide detectors.
(1) The licensee shall:
(i) Maintain at least one operable, automatic smoke detector on each floor, including the basement and attic.
|
Observations
Based on a review of the physical plant the recovey house failed to have operable, automatic smoke detectors in each floor.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The plan of correction was implemented on APRIL 27 2026 and it is the responsibility of the house manager to ensure that all smoke detectors are operable by completing a monthly test and documenting test .In the event of an inoperable smoke detector or expired batteries ,it will be replaced immediately .It is the house managers responsibility to ensure that this does not occur again by checking smoke detectors when on property. |