INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 0X7C6701 Treatment Trends 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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§ 717.22(b)(1) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(1) Disclosure to the resident of criteria for beginning and ending residency.
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Observations
Based on review of resident records the recovery house failed to have resident signatures for beginning and ending of residency, and rules signed with in 24 hours of arriving. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager and CEO will submit a request to the EMR platform to add the beginning of residency form to the new resident enrollment appointment type. House manager will book that appointment type into his calendar so all necessary documentation is completed within 24 hours of arriving. CEO reviews and approves/rejects documentation. |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
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Observations
Based on the physical plant inspection the recovery house failed to have a fire extinguisher inspected in the House Managers room.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager will coordinate with maintenance department to obtain fire extinguisher inspection. House manager will submit photo to CEO for verification of inspected extinguisher. |