INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, M6DT6701 Women Walking in Victory 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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§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
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Observations
Based on the request for records the recovery house was not able to locate 4 of 9 records requested.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The administrative assistant will keep all records, past and present, in a locked filing cabinet. A weekly records check will be conducted by an administrative assistant to ensure all documentation is completed correctly and present in the filing cabinet. This was implemented on April 30, 2026. |
§ 717.31(c)(2) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on review of resident records the recovery house did not report unusual incidents involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On May 13, 2026, the unusual incidents identified in the renewal have been submitted by the administrative assistant.
Going forward, all unusual incidents will be submitted within 3 business days. The administrative assistant is responsible for ensuring that this does not occur again by verifying that it has been submitted. |
§ 717.31(c)(4) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(4) An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
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Observations
Based on review of resident records the recovery house did not report unusual incidents involving the presence of police, fire, or ambulance personnel.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On May 13, 2026, the unusual incidents identified in the renewal have been submitted by the administrative assistant.
Going forward, all unusual incidents involving the presence of police, fire, or ambulance personnel will be submitted within 3 business days. The administrative assistant is responsible for ensuring this does not happen again by verifying that it has been submitted. |