INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25-26, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection E3KM6701 Keep It Green 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(c) LICENSURE House Manager
§ 717.15. House Manager.
(c) The house manager shall complete at least 6 hours of training in one or more of the following areas within 6 months of becoming house manager, and annually thereafter:
(1) Fiscal policy.
(2) Administration.
(3) Program planning.
(4) Quality assurance.
(5) Program licensure.
(6) Personnel management.
(7) Confidentiality.
(8) Ethics.
(9) Trends in drug use and misuse.
(10) Developmental psychology.
(11) Interaction of addiction and mental illness.
(12) Cultural awareness.
(13) Sexual harassment.
(14) Relapse prevention.
(15) Substance use disorders.
(16) Peer support or mutual aid groups.
(17) Best practices for medication control and self-administration.
(18) Infection control.
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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 at least 6 hours of training for the 2025 training year.Staff #1 was hired as the house manager on August 18, 202, and was still in this position at the time of the inspection. There was no documentation of the annual training required provided.Staff #2 was hired as the house manager on January 1, 2009, and was still in this position at the time of the inspection. There was no documentation of the annual training required provided.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will develop a training schedule for all employees by 4/15/26 with input from Director. House Manager will be responsible for keeping trainings up to date and making sure staff has required training for each year by monthly auditing files. |
§ 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, using a department approved curriculum within 90 days of hire.Staff #1 was hired as the house manager on August 18, 202, and was still in this position at the time of the inspection. There was no documentation for first aid training, being completed within 90 days of hire.Staff #2 was hired as the house manager on January 1, 2009, and was still in this position at the time of the inspection. There was no documentation for first aid training, being completed within 90 days of hire.Staff #3 was hired as a volunteer on January 1, 2009, and was still in this position at the time of the inspection. There was no documentation for first aid training, being completed within 90 days of hire.Staff #4 was hired as a staff on October 7, 2024, and was still in this position at the time of the inspection. There was no documentation for first aid training, 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
Director will inquire when scheduling CPR if First aid is available to be done this year. If not Director with the assistance of House Manager will locate an alternative course to get staff up to speed. |