INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, H5Y06701 Nehemiah 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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§ 717.19(b) LICENSURE Resident Rights
§ 717.19. Resident rights.
(b) The licensee shall obtain written acknowledgement by residents that they have received notice of their rights.
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Observations
Based on review of the resident records the recovery house failed to have written acknowledgement by residents that they have received notice of their rights. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Acknowledgement of resident rights will be signed at time of admission. The house manager will ensure that this citation does not reoccur by checking records weekly, beginning 7/29/2026, to ensure that all documentation is in the resident record. |
§ 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 review of resident records the recovery house failed to have a resident record for a requested record. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager will ensure that all paperwork required for a resident's record will be in the record at the time of admission. A checklist for all required documents for a resident record has been created. This will begin on 7/29/26. |
§ 717.22(b)(2)(iii) 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:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
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Observations
Based on review of the resident records the recovery house failed to complete the the following documentation, which must be signed by the resident, within 24 hours of arrival: (2) Resident orientation to the drug and alcohol recovery house which must include: (iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager has created a document of the recovery house supports, referrals for residents, and other essential services, which will be provided to the resident within 24 hours of arrival. This process was implemented on 8/3/26. |
? 717.22(b)(3)(i)-(ii) 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:
(i) Name.
(ii) Birth date.
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Observations
Based on review of the resident records the recovery house failed to have a complete basic personal data form. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The resident application has been updated to include a complete biopsychosocial for each resident, which will be given to each resident upon admission. This has been implemented as of 8/3/26. |
§ 717.22(b)(4) 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:
(4) Consent to residency.
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Observations
Based on review of the resident records, the recovery house failed to have a signed consent to residency within 24 hours of arrivl.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager will ensure that all resident have signed a consent to residency within 24 hours of arrival. Resident records will be review weekly by the house manager, beginning 7/29/2026 |
§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
Based on a review of resident records, the recovery house failed to notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager will ensure a resident will receive in writing, of the decision to end residency. The notice will include the reason and timeframe for ending residency. This will begin on 7/29/26.
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§ 717.26 LICENSURE Complaint management
§ 717.26. Complaint management.
The licensee shall develop and implement written policies and procedures for managing complaints from residents, family members and community members, which must include procedures for informing residents, family members and community members of the complaint process, including the ability to file a complaint with the Department.
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Observations
Based on review of the resident records the recovery house failed to inform residents of the complaint process, including the ability to file a complaint with the Department. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The resident handbook has been updated to include the residents right of the complaint process for DDAP, including the ability to file a complaint with the Department. This has been updated under Residents Rights section on 7/29/26. |
§ 717.27 LICENSURE Notification to family or emergency contact
§ 717.27. Notification to family member or emergency contact.
(a) The licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent. The resident may revoke consent to provide notice to the emergency contact.
(b) The licensee shall make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. This subsection shall not apply if the licensee knows or has reason to know of allegations of domestic abuse on the resident by the emergency contact.
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Observations
Based on review of resident records the recovery house failed to notify the resident ' s emergency contact in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The house manager will ensure that the resident ' s emergency contact will be contacted in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. This will be documented in the resident record beginning 7 29/26. |
§ 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 the resident records the licensee failed to file an unusual incident with the Department within 3 business days following an unusual incident involving an event at the drug and alcohol recovery house requiring 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
The house manager will file an unusual incident with the Department within 3 business days following an unusual incident involving an event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel. This will be effective immediately, beginning on 7/29/26.
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