INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 7, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, UNP46701 One Day at a Time 2 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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§ 717.18(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 review of the staff records the recovery house failed to provide (1) An assessment of training needs for each staff person and volunteer, (2) A plan for addressing those needs and (3) A mechanism to collect feedback on completed training. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.18(a) ? Staff Training Plan Requirements
Corrective Action Taken:
The facility will develop and implement a comprehensive Staff Training and Development Policy that includes:
- Individualized training needs assessments for all staff and volunteers
- Individual training plans based on role and identified needs
- A standardized training feedback form completed after each training
All current staff and volunteers will complete a retrospective training needs assessment and corresponding training plans as of.
Systemic Changes Implemented on 4/15/2026 and all training information will be available at time of renewal.
- A Training Needs Assessment Tool will be implemented and added to all personnel files
- A Training Plan Template is now required upon hire and updated annually
- A Training Feedback Form is required after each training session and maintained in training records
Monitoring Plan:
- The Program Director/House Manager will review all staff training files monthly for compliance
- A Training Compliance Log will be maintained and reviewed during monthly meetings
- Any deficiencies will be corrected within 5 business days
Responsible Staff: Program Director / House Manager
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§ 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 review of the staff records the recovery house failed to provide an evaluation of the training plan annually. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
717.18(b) ? Annual Evaluation of Training Plan
Corrective Action Taken:
An annual evaluation of the training program will be completed assessing staff compliance, training effectiveness, and gaps.
Systemic Changes Implemented on 04/15/2026
- An Annual Training Evaluation Tool has been developed
- The evaluation is now scheduled to occur every 12 months and includes review of all training records, staff feedback, and compliance.
The Monitoring Plan:
The Program Director /House Manager will ensure annual review is completed and documented.
Documentation will be maintained in a file.
Compliance will be reviewed during renewal.
Responsible Staff: Program Director/ House Manager
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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 review of the staff records the recovery house failed to provide proof of CPR 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
§ 717.18(c)(1) ? CPR Certification
Corrective Action Taken:
All current staff will be scheduled for and/or completed CPR certification as of
Systemic Changes Implemented on 04/08/2026
- CPR certification is now required within 90 days of hire and tracked via onboarding checklist
- Proof of certification is maintained in each personnel file
Monitoring Plan:
- House Manager/Program Director will track certification status using a Training Tracker Spreadsheet
- Monthly review of staff files to ensure compliance
Responsible Staff: Program Director / House Manager
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§ 717.18(c)(2) 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:
(2) First aid training, including training on overdose reversal medication.
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Observations
Based on review of the staff records the recovery house failed to provide proof of first aid training, including training on overdose reversal medication. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.18(c)(2) ? First Aid & Overdose Reversal Training
Corrective Action Taken:
All staff have completed or been scheduled for First Aid and Narcan/overdose reversal training.
Systemic Changes Implemented on 04/08/2026
- Required training added to onboarding process with 90-day deadline
- Partnerships established with certified trainers/providers if applicable
Monitoring Plan:
- Training completion tracked monthly
- Documentation maintained in personnel files and training log
Responsible Staff: Program Director/House Manager
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§ 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/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum completed 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
§ 717.18(c)(3) ? HIV/AIDS, TB, STD Training
Corrective Action Taken:
All staff have completed or been enrolled in Department-approved HIV/AIDS, TB, and STD training.
Systemic Changes Implemented on 04/08/2026
- Approved training sources identified and standardized
- Training added to onboarding checklist with 90-day requirement
Monitoring Plan:
- Monthly audit of training compliance
- Certificates maintained in personnel files
Responsible Staff: Program Director/House Manager
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§ 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. Findings: In 7 out of 10 resident discharge 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
§ 717.23 ? Notification of Decision to End Residency
Corrective Action Taken:
A Resident Discharge/Termination Notice Form will beimplemented. Missing documentation for recent discharges has been corrected where possible.
Systemic Changes Implemented on 04/08/2026
- Written notice is now required for all discharges, including:
oReason for discharge
oEffective date
oAppeal/reconsideration process
- Staff trained on proper discharge documentation procedures
Monitoring Plan:
- All discharges will be reviewed by the Program Director/House Manager prior to finalization
- Monthly chart audits (minimum 10% or 3 files) to ensure compliance
Responsible Staff: Program Director / House Manager
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§ 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 on review of the physical plant inspection the recovery house failed tokeep 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: Lights in ceiling throughout the building are not protected by light covers. These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
§ 717.29(b)(1) ? Physical Plant (Light Covers)
Corrective Action Taken:
Protective covers will be installed on all exposed ceiling lights on 05/15/2026
Systemic Changes Implemented:
- A Facility Maintenance Checklist will be implemented for weekly inspections
Monitoring Plan:
- Weekly walkthroughs conducted and documented
- Immediate correction of hazards within 24?72 hours
Responsible Staff: House Manager / Building Owner Maintenance Team
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§ 717.29(e)(5) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based physical plant inspection the recovery house failed to repair inoperable exhaust fans.These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
§ 717.29(e)(5) ? Bathroom Ventilation
Corrective Action Taken:
All inoperable exhaust fans will be repaired or replaced on 5/15/2026
Systemic Changes Implemented:
- Ventilation systems added to routine maintenance checklist
Monitoring Plan:
- Monthly inspection of all bathrooms
- Work orders documented and tracked
Responsible Staff: Building Owner Maintenance Team / House Manager
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§ 717.29(g)(2) LICENSURE Physical plant standards - Heating-Cooling
§ 717.29. Physical plant standards.
(g) Heating and cooling. The licensee:
(2) May not use or permit portable space heaters.
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Observations
Based on review of the physical plant inspection it was noted that there was a space heater in residents bedroom. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.29(g)(2) ? Prohibited Space Heaters
Corrective Action Taken:
The space heater was immediately removed from the resident bedroom.
Systemic Changes Implemented on 04/08/2026
- Policy updated to explicitly prohibit space heaters
- Residents notified and acknowledgment forms signed placed in files.
Monitoring Plan:
- Weekly room inspections
- Any prohibited items removed immediately
Responsible Staff: House Manager/All Residential Aides on shift.
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