INITIAL COMMENTS
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This report is a result of an renewal on-site licensure inspection conducted on March 10, 2026 through March 12, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 8M566701 TNH Sober Living was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
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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 1 out of 5 staff records the recovery house failed to maintain a personnel record for 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.
These findings were reviewed with the recovery house staff during the renewal inspection process.
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Plan of Correction
Prior to the inspection the Executive Director/House Manager created a Human Resources Documentation Tracker as an internal audit revealed that a Resident Lead's records were out of date. The Tracker includes all required HR Records for DDAP, as well as conditional formatting to highlight when expected documents are missing and/or approaching an out-of-date status according to DDAP's requirements and internal TNH policy. Specific folders for each employee are maintained in TNH's SharePoint. The Tracker also maintains documentation of information of Resident Leads Terminated, from 2/1/2026 onward. All Resident Leads that no longer work with TNH have their SharePoint folders migrated to a "Former Employees" section of SharePoint and are maintained for at least 7 years.
The Executive Director/House Manager utilizes the Tracker daily. A Managing Partner reviews the accuracy of the Tracker quarterly in terms of the records it reflects and to ensure there are no missing or out-of-date documents. The Managing Partner also reviews the Terminated Resident Leads section of the Tracker and SharePoint to ensure that all former Resident Leads records are maintained. These monitoring frequencies began prior to the survey by DDAP on 3/10/2026.
As these records were already out-of-date and missing, no correction of the specific cited finding can be completed. |