INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection B4026701 Holistic House, Llc was found not to 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 five resident records reviewed, the facility failed to obtain 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
1. How the facility will correct the deficiency
The facility has corrected the identified deficiency by updating the standard and required intake process to ensure all residents receive and acknowledge required documentation at the time of admission.
The following documents have been added to the facility's standard intake packet on December 14th 2025:
Residential rights as listed in 28 Pa. Code § 717.19
Residency agreement
Complaints and grievance procedures, including contact information for local DDAP authorities
For current residents admitted prior to this change, the facility will retroactively correct the deficiency. The Erin Gattuso- Head of administrative duties, will meet individually with each affected resident to review the required information and obtain completed and signed documentation acknowledging:
Residential rights as listed in 717.19
Residency agreement
Complaints and grievance procedures with DDAP contact information
All completed documents will be placed in the resident's chart.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence of this deficiency, the facility has implemented the following measures:
A mandatory intake checklist has been created and integrated into the orientation process.
The checklist must be completed for every new resident to verify that all required documents have been reviewed, completed, and placed in the resident's chart.
Required documents are now embedded into the standard intake packet, ensuring they cannot be omitted.
Ongoing compliance will be monitored through:
Routine chart audits conducted quarterly
Review of intake documentation during staff supervision
3. Person responsible for ensuring corrective actions are implemented
House Manager is responsible for completing the intake checklist and ensuring all required documentation is reviewed and signed at the time of resident orientation.
Head of administrative duties is responsible for retroactive correction for past residents and for overseeing ongoing compliance monitoring.
4. Date corrective action will be completed
The updated intake process for new residents was implemented on: February 15th 2026
Retroactive completion of documentation for current residents will be completed by: February 14th 2026
The facility will be in full compliance with the regulation by February 14th 2026
5. Reasonable timeframe
The corrective actions are reasonable and appropriate to the nature of the deficiency. The updated intake process was implemented immediately, and sufficient time has been allotted to meet individually with current residents to ensure full compliance.
6. Complete resolution of deficiency
This Plan of Correction fully addresses all components of the cited deficiency by:
Ensuring required documentation is provided at intake
Correcting missing documentation for current residents
Implementing safeguards to prevent future recurrence
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§ 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 five resident records reviewed, the facility failed to provide documentation, signed by the resident, disclosing the criteria for beginning and ending residency.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
1. How the facility will correct the deficiency
The facility has corrected the identified deficiency by updating the required intake documentation to ensure all residents receive written disclosure of program and residency requirements.
The following documents have been added to the facility's standard intake packet:
Residency requirements
Holistic House program requirements
Disclosure of the criteria for beginning and ending residency
Criteria for dismissal
Dismissal process
For current residents admitted prior to this change, the facility will retroactively correct the deficiency. Each affected resident will be asked to review and complete additional documentation acknowledging receipt of the above information. All completed documentation will be placed in the resident's record.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence of this deficiency, the facility has implemented the following measures:
The updated documents are now permanently included in the standard required intake packet.
A required intake checklist is used during resident orientation to verify that all disclosures have been reviewed, completed, and filed.
Intake documentation will be reviewed as part of routine chart audits to ensure ongoing compliance.
3. Person responsible for ensuring corrective actions are implemented
House Manager is responsible for ensuring the completion of all required intake documentation for new residents at the time of orientation.
Head of Administrative Duties is responsible for coordinating retroactive documentation for current residents and overseeing compliance monitoring.
4. Date corrective action will be completed
The updated intake documentation for new residents was implemented on: February 14th 2026
Retroactive completion of documentation for current residents will be completed by: February 14th 2026
The facility will be in full compliance with the regulation by February 14th 2026
5. Reasonable timeframe
The corrective actions are reasonable and appropriate given the nature of the deficiency. Intake process changes were implemented immediately, and adequate time has been allotted to meet with current residents to complete retroactive documentation.
6. Complete resolution of deficiency
This Plan of Correction fully addresses the cited deficiency by:
Ensuring all required residency and program disclosures are provided at intake
Correcting missing documentation for residents admitted prior to the update
Implementing safeguards to prevent future omissions
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§ 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 five resident records reviewed, the facility failed to provide a consent to residency which must be signed by the resident within 24 hours.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Head of Administrative Duties has added the consent to residency to the required intake form. The house Manager will ensure that all incoming residents sign this upon entering the home.
For current residents, the house of administrative duties, currently Erin Gattuso, will have each individual sign the residency rights. This will be completed by February 14th 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 two of two discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.
Resident # 4 was admitted on September 5, 2025, and discharged October 15, 2025. There was no documentation of an end to residency in the resident record.
Resident # 5 was admitted on March 3, 2025, and discharged March 28, 2025. There was no documentation of an end to residency in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The facility has corrected the cited deficiency by developing a new Standard Operating Procedure (SOP) to guide the House Manager in proper discharge protocols. The Head of Administrative Duties created this SOP to ensure consistency with discharge requirements.
A new discharge documentation form has been created and implemented within Sobriety Hub, the facility's electronic management software. This document is designated specifically for resident discharges and clearly outlines the types of discharge, provides definitions and explanations for each discharge category, and specifies appropriate reasons for ending residency.
The House Manager is responsible for implementing this SOP and completing the discharge documentation for all future discharges. This corrective action is being implemented immediately and will be used for all discharges going forward to ensure the deficiency does not recur.
To prevent future occurrences, the Head of Administrative Duties will monitor compliance through periodic chart reviews within Sobriety Hub to confirm that discharge documentation is completed accurately and in accordance with the SOP. Any identified issues will be addressed through additional training or corrective guidance as needed.
The facility will be in full compliance by February 14, 2026.
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§ 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 a review of resident records, the facility failed to provide documentation specifying the methods and circumstances including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent and that the resident may revoke consent to provide notice to the emergency contact in accordance with 717.27 (a).
Based on two of two 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 in accordance with 717.27 (b).
Resident # 4 was admitted on September 5, 2025, and discharged October 15, 2025. There was not a notification to the emergency contact provided in the resident record.
Resident # 5 was admitted on March 3, 2025, and discharged March 28, 2025. There was not a notification to the emergency contact provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The facility has corrected the cited deficiencies by updating its intake and discharge documentation processes to ensure compliance with 717.27(a) and 717.27(b).
An Emergency Contact Consent Form has been added to the required intake documentation. This form informs residents that the facility may notify their emergency contact in the event of death, hospitalization, or discharge, and clearly states that the resident may revoke consent to provide notice to the emergency contact in accordance with 717.27(a). The House Manager is responsible for reviewing this form with the resident at intake and ensuring it is fully completed and signed.
For individuals who discharged prior to December 11, this corrective action is not applicable, as they are no longer residents of the facility.
Additionally, the facility has updated its discharge documentation to require the House Manager to record:
The date the emergency contact was notified
Confirmation that the notification occurred
The House Manager's signature verifying completion
This documentation is now required for all applicable discharges in accordance with 717.27(b).
For any current residents, the head of adminstrative duties will have them sign this documentation.
The facility will be in full compliance by February 14, 2026. |