INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection LZUK6701 DePaul House 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 proof of assessment of training needs, a plan of addressing those needs, and 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
To Prevent recurrence, staff training needs will be assessed annually and upon hire with plans developed accordingly.
Feedback mechanism will be implemented after each training. All documentation will be maintained in employee files. Christelle Champagne, Associate Director, will oversee implementation and compliance.
Implementation will commence in September 2025 |
§ 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 proof of a reviewed training plan.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
DePaul House will ensure all training plans are reviewed annually and upon staff changes. Documentation of the review will be maintained in staff files.
A tracking system will be implemented for Compliance. Christelle champagne Associate Director will ensure follow-Through. With supervisions by Ricardo Torrez starting October 2025. |
§ 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/First Aid training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All staff will be required to complete CPF/First Aid Training within 30 days of hire. Current staff without proof will be scheduled immediately during the month of July and August for their training.
Christelle Champagne, Associate Director will ensure ongoing compliance. |
§ 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
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All DePaul staff will complete HIV/AIDS, tuberculosis, and STD training using a DDAP approved curriculum. Staff without proof of will be scheduled for immediate completion. Certificates will be kept in shared personnel file and in the employee's folder. A training log will be reviewed monthly by Christelle Champagne ,
AD to ensure ongoing compliance.
All staff mentioned during the DDAP inspection has been set up for training to be completed by the end of July. For the exception of Suzannah H that will be out of office and will have her trainings completed in August 2025 |
§ 717.18(c)(4) 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:
(4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
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Observations
Based on review of the staff records the recovery house failed to provide proof of fire prevention and emergency preparedness, including use of a fire extinguisher.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All staff will complete fire prevention and emergency preparedness training, including proper use of a fire extinguisher, within 30 days of hire.
Missing documentation will be addressed immediately. Training certificates will be filed in personnel records. Christelle C, AD will review compliance quarterly to ensure completion and documentation.
Training will take place by the end of August 2025. |
§ 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
Staff will document all attempts to notify emergency contacts within 12hrs when a resident leaves or fails to return.
Immediate training will be provided on this protocol. All communication attempts will be logged in resident files.
Documentation of all emergency contact attempts starts immediately.
This will be documented and monitored by all DePaul Residential Aid Staff and managers. |
§ 717.31(c)(4) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(4) An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
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Observations
Based on review of the resident records the licensee failed to file an unusual incident with the Department within 3 business days following an unusual incident involving an event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All DePaul House Staff will be retrained on reporting requirements for unusual incidents involving emergency personnel. A reporting log will be implemented to track timely submissions to DDAP.
Missed reports will be reviewed in supervision. Christelle C AD, will monitor compliance and ensure reports are filed within 3 business days.
Implementation starts immediately. |