INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection M5PU6701 Shane's 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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§ 717.18(c)(3) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on review of the staff records the recovery house failed to have staff complete required training within 90 days:
HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Plan of Correction
In a Leadership Team meeting on 10/24/25, the House Manager and Operationd Manager met to review the training requirements for staff working at our recovery house. Any staff member who had not received the following trainings were identified, and have been told they have until 11/7/25 to complete those trainings. The trainings are:
1) HIV/AIDS
2) TB/STD
Staff in need of these trainings were shown on 10/24/25, how and where they can register for and complete these trainings. |
§ 717.19(a)(1) LICENSURE Resident Rights
§ 717.19. Resident rights.
(a) The licensee shall develop and implement written policies and procedures on resident rights which must include:
(1) Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority.
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Observations
Based on review of the resident records the recovery house failed to include "Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority."
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On 10/27/25, the House Manager updated our Consent to Residency form to include all items mentioned in PA code 717.19, including this statement: "Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority." All clients receive and sign off on this form upon entry into residency. |
§ 717.22(b)(1) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
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Observations
Based on review of the resident records, the recovery house failed to notify residents of the reasons for ending residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In a team meeting on 10/24/25, Shane's House staff were re-educated on the purpose of the End of Residency Form. They were reminded of the importance of documenting the reason for the end of a client's residency which also requires that the client sign in acknowledgement. It is the responsibility of the House Manager to review all EOR forms to ensure these are being completed properly and clients are being informed. |
§ 717.22(b)(3)(vi) 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:
(vi) Medical contact information.
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Observations
Based on review of resident records the recovery house failed to collect medical contact information.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In a meeting on 10/24/25, staff we re-educated on the importance of documenting referrals to and from the drug and alcohol recovery house, if applicable, per PA 717.20. It is the responsibility of the House Manager to ensure any referrals being made are properly documented on the Personal Data Form for each client. |