INITIAL COMMENTS
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This report is a result of a renewal on-site licensure inspection conducted on July 7, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 9QDF6701 Transitioning Lives Llc. was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
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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 records, the facility failed to provide documentation of at least six hours of annual training being completed by the house manager. Staff #1 was hired as the house manager on January 1, 2024, and was still in this position at the time of the inspection. There was no documentation of six hours annual training completed.These findings were reviewed with the recovery house staff during the licensing process.This is a repeat citation from the July 23, 2025, annual licensing inspection.
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Plan of Correction
1. The current House Manager will complete any required annual training hours immediately and all certificates of completion will be placed in the employee's personnel file
2. A training log and compliance tracking system will be implemented for all staff to document required annual training hours, completion dates,training topics, and supporting certificates.
3. Due to repeat citation a facility will designate a supervisor to monitor training training requirements quarterly and notify staff 60 days before annual training is due to ensure completion.
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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 a review of staff records, the facility failed to provide documentation of all staff persons and volunteers to complete HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum within 90 days of hire. Staff #1 was hired as the house manager on January 1, 2024, and was still in this position at the time of the inspection. There was no documentation tuberculosis and sexually transmitted diseases training using a department approved curriculum being completed.These findings were reviewed with the recovery house staff during the licensing process.This is a repeat citation from the July 23, 2025, annual licensing inspection.
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Plan of Correction
1.The House Manager has been scheduled to complete the required Department approved TB and STD training immediately. Upon completion, a certificate of completion will be obtained and placed in the employee's personnel file to verify compliance.
2. To prevent future occurrences the House manager will implement a staff training compliance tracking system that documents all required trainings and their due dates.
3 Facility Director/Owner will be responsible with quarterly training audits and re-training of staff to ensure the deficiency does not reoccur. |
§ 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 two of seven resident ' s records reviewed, the facility failed to a consent to residency that must be signed within twenty-four hours of arrival.Resident # 3 was admitted June 1, 2026, and was still active at the time of the inspection. The resident ' s consent to residency was not signed until July 6, 2026.Resident # 6 was admitted on March 27, 2026, with an unknown discharge date. There was no consent to residency documented 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 missing Consent to Residency forms were immediately addressed. The house manager reviewed the forms of all current residents to ensure that a completed and signed Consent to Residency form is present in each residents file.
2.Effective immediately the house manager will complete an admission checklist for every new resident. The checklist will include verification that the Consent to Residency is reviewed, signed and filled within 24 hours of admission.
3. House Manager will conduct quarterly audits to verify compliance. |
§ 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 four discharged resident records reviewed, the facility failed to provide written notification to the residents stating the decision to end residency. The facility was not completing documentation to end residency and the reasons for residency ending.These findings were reviewed with the recovery house staff during the licensing process.This is a repeat citation from the July 23, 2025, annual licensing inspection.
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Plan of Correction
1. The facility had taken immediate corrective action to address this deficiency. A standardized resident discharge/termination form has been implemented to ensure all residents receive written notification when a decision is made to end Residency. The form documents the date Residency ended the reason for discharge or termination. and verifies that the resident was provided written notification.
2. To prevent recurrence, the House manager will complete a monthly audit of resident records to verify that all discharge documents are complete and in compliance. |
§ 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 four 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. Also, in resident record # 6, the facility failed to provide documentation that the facility will contact the designated emergency contact within 12 hours in the event of the residents hospitalization or death, or if the resident decides to end residency or does not return to the drug and alcohol recovery house as expected, including the notifying the resident they may revoke consent in accordance with 717.27 (a).Resident # 6 was admitted on March 27, 2026, with an unknown discharge date. There was no documentation of the resident being notified of the emergency contact information.These findings were reviewed with the recovery house staff during the licensing process.This is a repeat citation from the July 23, 2025, annual licensing inspection.
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Plan of Correction
1. All residents records have been reviewed to ensure that a emergency contact authorization and consent form is completed. This form includes notification that the resident may revoke consent at any time in accordance with applicable regulations.
2. The admission form has been revised to include documentation that the facility will contact the designated emergency contact within 12 hours in the event of hospitalization, death, decision to end Residency or failure to return to recovery house as expected.
3. A monthly quality assurance audit of residents by house manager to verify compliance and be immediately corrected. |