INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 2, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 0X7C6701 Treatment Trends Inc. 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 recovery house records the recovery house failed to notify the Department within 30 days of the change in house manager.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
House Manager form signed 7/1/25; emailed on 7/7/25.
If there are changes to the House Manager, the licensee will notify the Department in writing, within 30 days. |
§ 717.18(c)(3) 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:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on review of the staff records the recovery house failed to provide proof of HIV, TB/STD training within 90 days of hire.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Original Date of Hire: 2/22/24; Transferred to House Manager on 5/18/24; HIV Training was completed on 3/25/25.
DDAP TMS offers TB/STD training. House Manager will register for and attend training; submit certificate and evaluation to Administration and DDAP. |
§ 717.22(b)(3)(vi) 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:
(vi) Medical contact information.
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Observations
Based on review of the resident records, the recovery house failed to collect medical provider information in records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager is responsible for collecting medical contact information during the time of admission. It shall be added to the Primary Care Provider (PCP) section, indicating either the physician or N/A if no PCP is identified. All current residents' EMRs (Electronic Medical Records) will be audited for compliance, and that section will be completed in their respective EMR by the House Manager, by 8/31/25. All future residents' records will reflect the medical provider information collected during their admission. |
§ 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 the resident records, the recovery house failed to collect emergency contact information.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
The House Manager is responsible for collecting Emergency contact (EC) information at the time of admission to the recovery house. It is then noted in the Patient Info screen in the EMR (Electronic Medical Record). If there is no EC identified, the house manager will click the "Same as Patient" button. All current residents' EMRs will be audited for compliance, and that section will be completed in their respective EMR, by 8/31/25. All future residents' records will reflect the emergency contact information collected during their admission.
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§ 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 House Manager is responsible for making at least one attempt to notify the resident's emergency contact within 12 hours after not returning to the recovery house as expected and/or decision to end residency. That phone call and it's outcome shall be documented in the Patient Communication section of the EMR by the House Manager. After the House Manager finalizes the EMR, it is sent to a supervisor for review, who is responsible for ensuring that the admission and all collected info is in compliance. |