INITIAL COMMENTS
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This report is a result of a recovery house onsite complaint investigation conducted on March 13, 2025, to March 18, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Stop & Surrender Rainbow was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717, which pertains to the recovery house.
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Plan of Correction
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§ 717.29(b)(1) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(1) Keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
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Observations
Based on review of the physical plant kitchen area the licensee failed to keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
Fidnings: The kitchen and surrounding area was not clean, safe and sanitary.
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Plan of Correction
The on 03/24/25 the kitchen was thoroughly cleaned by staff-on-duty and residents. We had a DDAP licesning renewal phyiscal plant inspection on 03/25/2025 and there were no issues with cleanliness, safety, and/or sanitary conditions. Our inspection was completed by Anna Anderson of DDAP.
Staff will develop and weekly chore list which residents will be assigned certain household chores for one week and the assigned chores will rotate on a weekly basis. Also, staff and residents will complete a "GI" (thorough cleaning) every Saturday morning of the entire facility. The staff on duty will complete an inspection to determine if the GI meets our organization's clealiness standards. |
§ 717.29(b)(3) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(3) Keep the drug and alcohol recovery house free of rodent and insect infestation.
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Observations
Based on review of the physical plant kitchen area the licensee failed to keep the drug and alcohol recovery house free of rodent and insect infestation.
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Plan of Correction
On 03/28/2025 the Humane Wildlife and Pest Control company PA Lic# 851021 conducted a complete extermination process of the facility, paying special attention to our kitchen.
This service will occur at least one monthly or more if necessary to erradicate rodents and insects. |
§ 717.29(f)(2) LICENSURE Physical plant standards - Kitchens
§ 717.29. Physical plant standards.
(f) Kitchens. The licensee shall:
(2) Ensure that storage areas for foods are free of food particles, dust
and dirt.
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Observations
Based on review of the physical plant the licensee shall failed to ensure that storage areas for foods are free of food particles, dust and dirt.
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Plan of Correction
The on 03/24/25 the kitchen was thoroughly cleaned by staff-on-duty and residents. We had a DDAP licesning renewal phyiscal plant inspection on 03/25/2025 and there were no issues with cleanliness, safety, and/or sanitary conditions. Our inspection was completed by Anna Anderson of DDAP.
Staff will develop and weekly chore list which residents will be assigned certain household chores for one week and the assigned chores will rotate on a weekly basis. Also, staff and residents will complete a "GI" (thorough cleaning) every Saturday morning of the entire kitchen and food storage area. The staff on duty will complete an inspection to determine if the GI meets our organization's clealiness standards. |
§ 717.29(f)(4) LICENSURE Physical plant standards - Kitchens
§ 717.29. Physical plant standards.
(f) Kitchens. The licensee shall:
(4) Ensure that food items are stored off the floor.
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Observations
Based on review of the kitchen the licensee failed to ensure that food items are stored off the floor.
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Plan of Correction
The on 03/24/25 the kitchen was thoroughly cleaned by staff-on-duty and residents. All food items are now stored on a shelf to comply with safety standards. We had a DDAP licesning renewal phyiscal plant inspection on 03/25/2025 and there were no issues with cleanliness, safety, and/or sanitary conditions. Our inspection was completed by Anna Anderson of DDAP.
Staff will develop and weekly chore list which residents will be assigned kitchen clean-up chore for one week and the assigned chores will rotate on a weekly basis. The assigned chores will be a requirement for residents to complete at least once daily. Our resident food coordinator will assist with maintaining clealiness of the kitchen as well. Also, staff and residents will complete a "GI" (thorough cleaning) every Saturday morning of the entire kitchen. The staff on duty will complete an inspection to determine if the GI meets our organization's clealiness standards. |
§ 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 review of the physical plant in the kitchen the licensee failed to 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.
Findings: The kitchen fire extinguisher tag showed that the last inspection was 2022.
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Plan of Correction
On 03/18/2025 a replacement tab was received from Boardman Fire Extinguisher CO. LIC# P00214 and reattached to the fire extinguisher in the kitchen. The tag shows that the fire extinguisher was last inspected in September 2024. (Original tag was lost or taken off).
Plan of correction, moving forward the facility will maintain copies/pictures of each fire extinguisher tag and file in the Fire Log book to prove that each extinguisher was inspected and in compliance with the regulation's standard. |