INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 22-23, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, Recovery Center of America at Devon was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation:
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times.
DDAP staff completed a physical plant inspection and observed the following:
* Room #E-543, a black mold like substance on the grout in the shower.
* Room #E-504, slow drain in the bathroom sink
*Room #E 404, a black mold like substance on a support plank under the bathroom sink.
* Kitchen, a ceiling HVAC vent was dripping water and had a black mold like substance on the vent cover.
These findings was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Effective 7/22/2026, patient room E-543's shower had its drain treated with Terro foaming insect killer and the caulk was scraped and re-laid.
Effective 7/23/2026, patient room E-504's bathroom sink was snaked and treated with Terro foaming insect killer.
Effective 7/23/2026, patient room E-404 had the identified piece of wood removed and a new bracket was mounted securing the sink appropriately.
Effective 7/23/2026, kitchen's ceiling HVAC vent was taken down and thoroughly cleaned. When remounted, the new insulation was treated with a mold repellant chemical prior to being placed back up with the vent.
Effective 9/1/2026, Facilities personnel and/or their designee will complete a minimum of (10) patient room inspections a month as part of their Environment of Care walkthrough process. Any needed repairs identified during the room inspections will have a work order created in the facility's electronic system and have an email sent to the Director of Facilities in real time to ensure repairs are addressed in a timely fashion. The results of the patient room inspections will be discussed during the monthly Safety Committee Meeting.
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection, the facility failed to keep the facility free of rodent and insect infestation.
DDAP staff completed a physical plant inspection and observed the following:
* Room E-543, live insects crawling around the bathroom shower drain.
* Room E-405, dead insects stuck to the top of the bathroom shower stall.
These findings was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Effective 7/22/2026, patient room E-543's shower drain was cleaned and treated with Terro foaming insect killer.
Effective 7/23/2026, patient room E-405's shower stall was deep cleaned and treated with Terro foaming insect killer.
Effective 9/1/2026, RSS Staff will begin completing "Patient Room Check" checklists in collaboration with the patient occupying the room to ensure there is accountability for overall room cleanliness. Any needed repairs identified during the room checks will have a work order created in the facility's electronic system and have an email sent to the Director of Facilities in real time to ensure repairs are addressed in a timely fashion. The "Patient Room Check" checklist will be submitted to the RSS Supervisor at the conclusion of each shift and reviewed by the RSS Supervisor at least weekly to identify trends and ensure overall procedural compliance. The results of the checklist ongoing review, in conjunction with the electronic work order system review, will be discussed and trends identified during the monthly Safety Committee Meeting.
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