INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, DJ6Y6701 Cold Bore Recovery 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(b) LICENSURE House Manager
§ 717.15. House Manager.
(b) The licensee shall identify the house manager in the application submitted to the Department and shall notify the Department in writing any time the house manager changes within 30 days.
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Observations
Based on review of the personnel files the recovery house failed to notify the Department in writing any time the house manager changes within 30 days.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.15(b) ? House Manager
The Department has updated its records to reflect the current House Manager. Going forward, the Executive Director will notify the Department in writing within 30 days of any change in House Manager. The Operations Manager will maintain documentation of the notification in the facility's administrative records and verify compliance during annual licensing preparation.
Persons Responsible: Executive Director and Operations Manager
Date of Full Compliance: Currently in full compliance |
§ 717.22(b)(2)(i) 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:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(i) Drug and alcohol recovery house rules, including a method to record residents' expected return time to the drug and alcohol recovery house.
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Observations
Based on review of the resident records the recovery house failed to have residents sign document withn 24 hours stating that they have been made aware of resident orientation to the recovery house including house rules
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.22(b)(2)(i) ? Beginning of Residency
Effective June 22, 2026, the House Manager or designated admission staff will review the recovery house rules and the method for recording expected return times with each new resident and obtain the resident's signed acknowledgment within 24 hours of arrival.
The Operations Manager will train applicable staff on this requirement by June 27, 2026. The House Manager will review each new resident file within 24 hours of admission to confirm the signed documentation is complete. The Operations Manager will conduct monthly file reviews and provide corrective training when necessary to maintain ongoing compliance.
Persons Responsible: House Manager and Operations Manager
Date of Full Compliance: June 26, 2026 |