INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 8, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection RZLS6701 Addiction - Serving People With Opioid And Other Drug Treatment 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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§ 717.29(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 141 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Following the inspection, the issue regarding the bathroom hot water temperature has been corrected. The water temperature has been adjusted to remain below 120°F in compliance with the regulation.
To prevent recurrence, the House Manager will conduct weekly checks of the hot water temperature and document the results to ensure ongoing compliance with § 717.29(e)(3). |
§ 717.29(e)(5) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to provide ventilation by exhaust fan or window in each bathroom. The bathroom window did not open and there was not an exhaust fan.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Response to Deficiency ? § 717.29(e)(5) Physical Plant Standards ? Bathrooms
Following the inspection, corrective action has been taken to ensure all bathrooms are properly ventilated in accordance with § 717.29(e)(5). The bathroom windows were repaired to allow them to open, and exhaust vents were also installed in both bathrooms to provide adequate ventilation.
To prevent reaccurance of this deficiency1. House Manager will implement a weekly inspection process to monitor compliance with DDAP regulations related to this deficiency.2. A written inspection checklist will be developed and completed during each weekly review to ensure all requried areas are addressed.3. Any identified issues will be corrected immediately,and documentation of inspection and corrective action will be maintained in a compliance binder for review.4. Amonthly summary log will also be created to track trends and demostrate ongoing compliance efforts. 5. I will maintain oversight of all documentation and ensure that future submissions to DDAP are reviewed for accuracy prior to submission. |