INITIAL COMMENTS
|
This report is a result of an renewal on-site licensure inspection conducted on May 21, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, WESL6701 Friendship First was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
|
Plan of Correction
|
§ 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.
|
Observations
Based on a review of staff records it was determined the recovery house failed to collect feedback on completed training. These findings were reviewed with recovery house staff during the renewal inspection process.
|
Plan of Correction
Homeowner and Recovery House manager will have a signed training feedback submitted for official records by Dec 31 of 2026 and each Dec 31 of subsequent years. |
§ 717.18(b) LICENSURE Training
§ 717.18. Training.
(b) The licensee shall conduct and document an evaluation of the training plan annually.
|
Observations
Based on a review of staff records it was determined the recovery house failed to conduct and document an evaluation of the staff training plan annually. These findings were reviewed with recovery house staff during the renewal inspection process.
|
Plan of Correction
Recovery house will document and evaluate staff training annually by Dec 31 of calendar year. |
§ 717.22(b)(3)(vii) 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:
(3) Basic personal data including:
(vii) Emergency contact.
|
Observations
Based on a review of resident records the licensee failed to complete the following documentation which must be signed by the resident within 24 hours of arrival- obtaining emergency contact information.
|
Plan of Correction
House manager will collect emergency contact information and document if a resident does or does not provide the emergency contact information within 24 hours of arrival. |