INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection E4G46701 Central Pennsylvania Recovery Associates, Llc. 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 a review of the house manager personnel record, the recovery house failed to provide feedback on completed trainings and a training plan for the next training year.
The house manager was hired in this position on February 1, 2023. The trainings provided for the training year did not provide training feedback forms. Also, there was not a training plan developed for the next training year.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
A revision was made to the Training Policy and a procedure was developed, along with a Training Plan Form and Training Feedback Plan Form being created.
A training plan for the 1 staff member was written and available to share.
The House Manager is responsible for corrective action and the House Manager will monitor and ensure it does not recur. |
§ 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 upstairs bathroom was read at 137 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Water temp on heater adjusted and temperature verified. Lock placed on basement door to prevent guests from adjusting.
The House Manager is responsible for corrective action and the House Manager will monitor and ensure it does not recur. |
§ 717.30(b)(1) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(1) Ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed. The ladder designated for the emergency exit was obstructed by a bed and not accessible.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Bed moved to other side of room, resident instructed to quit moving the bed. Training provided to all house members the importance of keeping fire ladders clear.
The House Manager will weekly check the compliance and make sure the beds are no in front of the exit. House Manager will train all new incoming residents of this policy. |