INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 6N9M6701 3837-Walnut Street 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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§ 717.17(c) LICENSURE Personnel Management
§ 717.17. Personnel management.
(c) The licensee shall maintain a personnel record for the house manager and each staff person and volunteer, which must include:
(1) Application or resume.
(2) A Pennsylvania State Police criminal history record check.
(3) Disciplinary actions.
(4) A written job description for each drug and alcohol recovery house position.
(5) Documentation of training.
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Observations
Based on a review of staff # 2's personnel record, the facility failed to provide documentation of a complete personnel record to include: (1) Application or resume. (2) A Pennsylvania State Police criminal history record check. (3) Disciplinary actions. (4) A written job description for each drug and alcohol recovery house position. (5) Documentation of training. Staff #2 was hired as the certified recovery specialist on July 15, 2024, and was still in this position at the time of the inspection. There was no documentation provided of a complete personnel record.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
An electronic personnel file for staff #2 containing items 1-5 is complete. An electronic personnel file will be completed for all new hires. The house manager will ensure the required information for all new hires and existing staff is maintained by review of the personnel files quarterly. |
§ 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 a review of the house manager ' s personal record, the facility failed to provide documentation of the house manager completing a feedback form for the training completed for the 2025 training year.Staff #1 was hired as the house manager on March 1, 2020, and was still in this position at the time of the inspection. There was no documentation of feedback forms for completed training provided.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Effective immediately, feedback forms for all training within 5 days of completion of any training will be completed and retained by licensee in staff personnel files. Completion of the feedback forms will be ensured by a director of the licensee by a quarterly review of the personnel files of all staff. |
§ 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 a review of staff records, the facility failed to provide documentation for all staff persons and volunteers to complete Cardiopulmonary resuscitation (CPR) certification training using a department approved curriculum within 90 days of hire.Staff #1 was hired as the House manager on March 1, 2020, and was still in this position at the time of the inspection. There was no documentation of Cardiopulmonary resuscitation (CPR) certification using a department approved curriculum that was completed.Staff #2 was hired as the Certified Recovery Specialist on July 15, 2025, and was still in this position at the time of the inspection. There was no documentation of Cardiopulmonary resuscitation (CPR) certification using a department approved curriculum that was completed.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
CPR training for current staff will be completed within 90 days. Certificates and feedback forms for the training will be maintained in personnel files. A director will review personnel files quarterly to ensure compliance with regulatory training requirements. |
§ 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 a review of staff records, the facility failed to provide documentation for all staff persons and volunteers to complete first aid training, including training on overdose reversal medication training using a department approved curriculum within 90 days of hire.Staff #1 was hired as the house manager on March 1, 2020, and was still in this position at the time of the inspection. There was no documentation of first aid training, including training on overdose reversal medication being completed within 90 days of hire.Staff #2 was hired as the certified recovery specialist on July 15, 2024, and was still in this position at the time of the inspection. There was no documentation of first aid training, including training on overdose reversal medication being 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
First aid training for current staff will be completed within 90 days. Certificates and feedback forms for the training will be maintained in personnel files. A director will review personnel files quarterly to ensure compliance with regulatory training requirements. |
§ 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 a review of staff records, the facility failed to provide documentation of all staff persons and volunteers to complete HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum within 90 days of hire. Staff #1 was hired as the House manager on March 1, 2020, and was still in this position at the time of the inspection. There was no documentation of HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum was completed.Staff #2 was hired as the Certified Recovery Specialist on July 15, 2025, and was still in this position at the time of the inspection. There was no documentation of HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum was completed.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
HIV/AIDS, tuberculosis and STD training for current staff will be completed within 90 days. Certificates and feedback forms for the training will be maintained in personnel files. A director will review personnel files quarterly to ensure compliance with regulatory training requirements. |
§ 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 a review of staff records, the facility failed to provide documentation for all staff persons and volunteers to complete fire prevention and emergency preparedness, including use of a fire extinguisher within 90 days of becoming an employee or volunteer.Staff #2 was hired as the certified recovery specialist on July 15, 2024, and was still in this position at the time of the inspection. There was no documentation of fire prevention and emergency preparedness, including use of a fire extinguisher being 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
Fire prevention and emergency preparedness, including use of a fire extinguisher training for current staff will be completed within 90 days. Certificates and feedback forms for the training will be maintained in personnel files. A director will review personnel files quarterly to ensure compliance with regulatory training requirements. |
§ 717.22(a)(2) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(a) The licensee shall develop and implement written policies and procedures for beginning of residency which include:
(2) Requirements for completion of residency by meeting a resident ' s treatment, personal or financial goals or social-emotional or other needs.
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Observations
Based on all resident records reviewed, the facility failed to include the requirements for completion of residency by meeting a resident ' s treatment, personal or financial goals or social-emotional or other needs in the beginning of residency requirements.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Licensee amended its intake forms to list proposed goals and needs of the resident. The house manager individually reviews intake materials with each new resident. The resident signs an acknowledgement of review and receipt of intake forms, a copy of which is maintained in Sobriety Hub. A quarterly review of intake forms will be completed by a director to ensure compliance. |
§ 717.22(a)(3) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(a) The licensee shall develop and implement written policies and procedures for beginning of residency which include:
(3) Criteria for ending residency before completion under paragraph (2), including a timeline.
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Observations
Based on all resident records reviewed, the facility failed to include the criteria for ending residency before completion under paragraph (2), including a timeline in the beginning of residency requirements.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Residents are advised that a minimum six-month term of residency is suggested. Licensee's House Rules require two-weeks written notice of intent to vacate the facility if the resident is in good standing and compliant with such rules. The rules also advise the resident that an initial rule violation will be addressed verbally, with each subsequent violation addressed in writing on a DDAP approved form. Further, the rules provide two written violations can at the discretion of the Board of Directors result in termination of residency within 48 hours of notice. Theft, assault, use/abuse of drugs or other serious rule violation may result in immediate termination. All intake forms will be reviewed by a director to ensure compliance with regulatory requirements. |
§ 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 seven resident records reviewed, the facility failed to include 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
On or before 1/12/2026, the facility will utilize a composition book for residents to sign in and out. The house manager is responsible for reviewing the log book and providing a new book once the book is full. The books will be retained by the facility. |
§ 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 facility failed to provide documentation specifying the methods and circumstances including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent and that the resident may revoke consent to provide notice to the emergency contact in accordance with 717.27 (a). Based on three of three applicable discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected in accordance with 717.27 (b).Resident #5 was admitted on June 30, 2025, and was discharged August 22, 2025. There was no notification to the emergency contact provided in the resident record.Resident #6 was admitted on August 14, 2025, and was discharged August 31, 2025. There was no notification to the emergency contact provided in the resident record.Resident #7 was admitted on March 28, 2025 and was discharged August 3, 2025. There was no notification to the emergency contact provided in the resident record.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The licensee's policy on this issue is set forth in pertinent part below:
The House Superintendent or Board member will notify the Emergency Contact of the injured party as soon as practicable but in no event more than 12 hours after the incident. If a resident decides to end residency or does not return to the facility as expected or the resident's whereabouts are unknown for a period of 12 hours the resident's emergency contact shall be notified within 12 hours. Residents may revoke consent to provide notice to the emergency contact if done so in writing. The licensee's Critical Incident /Discharge form will be amended on or before 1/12/2026. The house manager is responsible for ensuring compliance with this regulation. |
§ 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 a physical plant inspection, the facility failed to maintain 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. The stairs from an emergency exit were covered with snow and a hazard.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager was advised that in addition to ensuring the walkways are free of snow and ice, the fire escape must be maintained in a similar condition. The house manager will ensure compliance by inspecting the grounds following a snow or ice event to ensure prompt removal of any hazards. |
§ 717.29(d)(1)(v)(C) LICENSURE Physical plant standards - Sleep accomodation
§ 717.29. Physical plant standards.
(d) Sleeping accommodations.
(1) Each drug and alcohol recovery house bedroom must have the following:
(v) At least 50 square feet of floor space per resident measured wall to wall in each shared bedroom with bunk beds. Bunk beds must:
(C) Be equipped with securely attached railings on each open side and open end of the bunk.
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Observations
Based on a physical plant inspection, the facility failed to equip a securely attached railing on each open side and open end of the bunk bed. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Any bunk bed being used by a resident, will have the required railings installed on or before 1/31/2026. The house manager will ensure compliance with the regulation during daily house inspections. |
§ 717.29(e)(3) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120°F.
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Observations
Based on a physical plant inspection, the facility failed to keep the water temperature from exceeding 120 degrees Fahrenheit. The water temperature in the bathroom was read at 138 degrees Fahrenheit.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The hot water heater's setting will be set to no higher than 120 degrees. The house manager will check the setting during daily house inspections to ensure compliance with this regulation. |