INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25-26, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection OVX06701 Keep It Green 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 the house manager ' s personal record, the facility failed to provide documentation of the house manager, completing at least 6 hours of training for the 2025 training year.
Staff #1 was hired as the house manager on August 18, 202, and was still in this position at the time of the inspection. There was no documentation of the annual training required provided.
Staff #2 was hired as the house manager on January 1, 2009, and was still in this position at the time of the inspection. There was no documentation of the annual training required provided.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will develop a training schedule for all employees by 4/15/26 with input from Director. House manager will be responsible for keeping trainings up to date and making sure staff has required training for each year with monthly file audits.
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§ 717.18(c)(2) 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:
(2) First aid training, including training on overdose reversal medication.
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Observations
Based on a review of staff records, the facility failed to provide documentation for all staff persons and volunteers to complete first aid training, using a department approved curriculum within 90 days of hire.
Staff #1 was hired as the house manager on August 18, 202, and was still in this position at the time of the inspection. There was no documentation for first aid training, being completed within 90 days of hire.
Staff #2 was hired as the house manager on January 1, 2009, and was still in this position at the time of the inspection. There was no documentation for first aid training, being completed within 90 days of hire.
Staff #3 was hired as a volunteer on January 1, 2009, and was still in this position at the time of the inspection. There was no documentation for first aid training, being completed within 90 days of hire.
Staff #4 was hired as a staff on October 7, 2024, and was still in this position at the time of the inspection. There was no documentation for first aid training, being completed within 90 days of hire.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Director will inquire when scheduling CPR if First aid is available to be done this year. If not Director with the assistance of House Manager will locate an alternative course to get staff up to speed. First aid will be added to annual training plan for continued monitoring. |
§ 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 two of three applicable discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected within 12 hours.
Resident #3 was admitted on September 15, 2025, and was discharged September 27, 2025. The emergency contact was not notified of the resident ending residency until September 29, 2025.
Resident #5 was admitted on February 16, 2026, and discharged March 2, 2026. The emergency contact was not notified of the resident ending residency until September 29, 2025.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All staff will immediately begin adding a time of departure and time of notification on the final note in each resident file. Also House Manager has already implemented a weekly updated sheet of all resident's emergency contact information to be kept with our worksheets in order keep such information easily accessible to staff in all areas where it would be pertinent. House Manager will check with staff daily to ensure emergency contacts have been notified of any departure. |