INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, FBHT6701 Phoenix House 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(c) LICENSURE House Manager
§ 717.15. House Manager.
(c) The house manager shall complete at least 6 hours of training in one or more of the following areas within 6 months of becoming house manager, and annually thereafter:
(1) Fiscal policy.
(2) Administration.
(3) Program planning.
(4) Quality assurance.
(5) Program licensure.
(6) Personnel management.
(7) Confidentiality.
(8) Ethics.
(9) Trends in drug use and misuse.
(10) Developmental psychology.
(11) Interaction of addiction and mental illness.
(12) Cultural awareness.
(13) Sexual harassment.
(14) Relapse prevention.
(15) Substance use disorders.
(16) Peer support or mutual aid groups.
(17) Best practices for medication control and self-administration.
(18) Infection control.
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Observations
Based on a review of staff records, the House Manager failed to complete 6 hours of training annually using a department approved curriculum.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will complete six hours of training each year using approved curriculum effective 5/15/2026. A quarterly review of training will be completed to ensure that the six hours will be completed before the next renewal onsite.
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§ 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 a review of resident records, the recovery house failed to report an unusual incident to the Department within three days that was a result of resident death while residing at the drug and alcohol recovery house.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of 5/15/2026 the Facility Director will document and report an unusual incident to the Department within three days that was a result of resident death while residing at the drug and alcohol recovery house. The House Manager will report any unusual incident to the Facility Director within 24 hours so that there is plenty of time to notify DDAP.
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