INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection JDTI6701 The Pocket 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 staff training records the recovery house failed to provide a mechanism to collect feedback on completed trainings.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On September 2, 2025, the deficiency has been corrected by retraining staff on completing the feedback form on all completed trainings. the feedback form was created on August 29, 2025 by the Director of Human Resources. In order for this deficiency to not re-occur, the Director of Human Resources will review staff records monthly to ensure the feedback form is being completed. In the event of an incomplete feedback form, the Director of Human Resources will promptly have employee complete the feedback form. |
§ 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 the staff training records the recovery house failed to provide HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On August 7, 2025, the Director of Human Resources reviewed employee records to compile a list of outstanding trainings needed. The Director of Human Resources informed the affected employees of their training needs and proposed a 1 week deadline to complete trainings which were met. To ensure this deficiency does not re-occur, the Director of Human Resources require all newly hired employees complete these trainings within their first 3 month of employment. The Director of Human Resources will track this via monthly employee record check. |
§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
Based on a review of resident records, the recovery house failed to provide a written notification to the resident stating the decision to end residency in 1 out of 4 discharge records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On August 19, 2025, the Director of Compliance implemented a policy for Administrative Discharges. The Director of Compliance informed the staff the client must be presented in writing with the reason why they are being administratively discharged with the right to appeal as well as the appeal process. If the client chooses to appeal, they will also receive the appeal results verbally and written. Emergency contact will also be contacted if the client is administratively discharged. To ensure this deficiency does not re-occur, the Director of Compliance will review all unsuccessful discharges immediately. |