INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 16OT6701 Central Pennsylvania Recovery Associates, Llc 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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§ 717.22(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
A beginning / ending of residency criteria form has been created and will be instituted by the house manager on all future intakes.
A paragraph being more descriptive has been added to the handbook as well.
The house manager will make sure that this occurs on every intake. This correction has already taken place. The house manager and owner will review all resident records quarterly to ensure 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 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 March 29, 2025, and discharged October 10, 2025. There was no documentation of an end to residency in the resident record.
Resident # 5 was admitted on January 4, 2025, and discharged October 10, 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 End of Residency form has been updated to include date and time exited along with date and time emergency contact has been notified. This form will be used on all future exits, successful or non-successful.
The house manager will make sure this occurs on every exit and the owner will review all records quarterly to assure compliance.
This will be audited quarterly by the owner to be assured this does not occur again. |
§ 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 one 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.
Resident # 5 was admitted on January 4, 2025, and discharged October 10, 2025. There was no notification to the emergency contact provided in the resident record. Contact was made with someone not designated as the emergency contact.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The End of Residency form has been updated to include date and time exited along with date and time emergency contact has been notified. This form will be used on all future exits, successful or non-successful.
The house manager will make sure this occurs on every exit and the owner will review all records quarterly to assure compliance.
This will be audited quarterly by the owner to be assured this does not occur again. |
§ 717.30(b)(1) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(1) Ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed. The emergency exit on the third floor was obstructed and not easily accessible.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The items blocking the 3rd floor fire exit were removed immediately during the inspection to create a clear path to the exit by the housing manager.
The house manager will audit this weekly to be sure it does not happen again. |