INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 9OFP6701 Rios Recovery 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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§ 717.12 LICENSURE Refusal or revocation of license
§ 717.12. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the
Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the drug and alcohol recovery house.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or
attempting to obtain a license.
(6) Lending, borrowing or using the license of another drug and alcohol recovery house.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing residents at the drug and alcohol recovery house.
(9) Continued noncompliance in disregard of this part.
(10) Operating a drug and alcohol recovery house that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the applicant or licensee by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the drug and alcohol recovery house to correct deficiencies.
(c) If the drug and alcohol recovery house does not correct the deficiencies within the specified time, the Department will officially notify the applicant or licensee that it shall show cause why its license should not be denied or revoked under 1 Pa. Code § 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. The applicant or licensee shall file a written request within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code § 35.14.
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Observations
Based on a review of prior renewals the recovery house did not follow through with a directive issued by the Department and a plan of correction approved by the Department.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On July 1st 2025, during the renewal process with Antoinette, I, the House Manager was informed that the resident roster with resident's information was missing a second year in a row and that emergency contact information was also missing by not being documented when resident's emergency contacts were contacted. This is the House Manager's responsible to have all information correctly documented and correctly filed and ready and accessible at the time of licensing process. I the House Manager have made an Emergency Contact table/form on 7-21-25 to help be better organized in the future and that nothing is missed during the emergency contact process. The House Manager fully understands what the Resident Roster contains and how it needs to be filled out and what needs to be provided for future renewal process. These corrections were made on 7-18-25 once I fully clarified and understood the essentials I was missing during renewal process. |
? 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 house manager trainings the house manager failed to 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:
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
on July 21st, the house manager has completed the correct annual training. A 3 hour ethic course, a 3 hour substance use disorder confidentiality course and a 2 and a half hour addiction 101 course.
The house manager fully understands now what the annual 6 hour training course contains and where to locate the trainings so that this mistake and citation does not happen again
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§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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Observations
Based on review of the staff records the licensee failed to complete an assessment of training needs, a plan for addressing those needs and time frame for completion, and a mechanism to collect feedback on completed trainings.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On 7-23-25, I the recovery house manager created a training assessment form for the house manager and employees to fill out annually and up to 90 days after hiring process. The house manager is in charge of giving out the assessment to any employees to fill out after they have completed their training courses or certifications. The house manager is in charge of going over the form with the staff to evaluate if everything was done on time and if anything training is missing. The house manager is also in charge of filling out the form themselves annually. I have filled out this form on 7-23-25 and sent it to Antoinette. Any forms filled out will be sent to Antoinette and will be filed in a folder.
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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 the staff training records the recovery house failed to provide a certificate for tuberculosis and sexually transmitted diseases training using a department approved curriculum.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of July 7th 2025, the house manager has completed her course for tuberculosis. The certificate was emailed over to Antoinette on 7/18/2025. The house manager fully understands what all trainings and certifications that will need to be done annually. STD certificate was done in 2023. |
§ 717.21(a) LICENSURE Resident Roster
§ 717.21. Resident roster.
(a) The licensee shall maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
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Observations
Based on a review of resident records, the recovery house failed to provide a resident roster outlining the name, date of admission and discharge dates
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Rios Recovery will make sure moving forward that I will have a resident roster with all the outlining information required. I understand that all information needs to be put all together on one form and ready upon meeting time. This plan of correction was implemented on 7/17/2025 |
§ 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 licensee failed to provde information regarding supports provided by the drug and alcohol recovery house which must include supports provided by the drug and alcohol recovery house, as well as referral to other essential services as needed.
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Plan of Correction
I the House Manager of Rios Recovery updated the recovery support section in the Orientation Handbook as of 7/17/2025. The Handbook provides multiple resources for anyone looking for additional care or support in their recovery. Names, facilities, addresses, and numbers were provided. The revised Handbook was sent to Antoinette on 7/18/2025. Once the revised Handbook is approved, the house manager will remove all old orientation Handbooks from the recovery houses and will hang up the new Orientation Handbook. New Handbooks will be read over with each resident by the team leader. Every new resident coming into Rios Recovery will read and go over the new Handbook with either the team leader, staff or house manager. The House Manager is available to the residents if they have any further questions with the additional support services. |
? 717.22(b) 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.
(2) Resident orientation to the drug and alcohol recovery house which must include all of the following:
(i) Drug and alcohol recovery house rules, including a method to record residents ' expected return time to the drug and alcohol recovery house.
(ii) Fee schedule including any lease agreement.
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
(iv) Financial policies and procedures.
(v) The location of posted emergency procedures and contact information for the house manager and the Department.
(vi) Medication control and self-administration policies.
(3) Basic personal data including:
(i) Name.
(ii) Birth date.
(iii) Demographic information.
(iv) Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker and other medical conditions that the resident chooses to have in the house record.
(v) Drug and alcohol history.
(vi) Medical contact information.
(vii) Emergency contact.
(4) Consent to residency.
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
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Observations
Based on review of the resident records, the recovery house failed to collect full personnel date infomration.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On July 19th 2025, the membership application form was revised by the house manager and sent to Antoinette with approval. It was addressed on July 1st 2025 with the house manager, team leader, and staff that not all information on the form was collected or filled out properly by the residents. The house manager informed staff and team leader to always review all information is properly collected and documented. As the house manager, I will review all the records on an ongoing basis to ensure that all information is being filled out correctly. |
§ 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 recovery house failed to notify the emergency contact in 2 out of 3 discharge records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Rios Recovery understands that when emergency contacts are being notified that it is documented on paper when the emergency contact was contacted, who they were contacted by and what the result of that contact was. This plan of correction has been implemented as of 7/17/2025. The house manager or staff will be in charge of contacting and documenting the emergency contact. The house manager has made a Emergency Contact Table form so that all information can be documented and no details will be missed moving forward. The house manager will share the form with staff. |
§ 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 the physical plant inspection the licensee failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
Findings: The bedroom windows on second and third floor that are used for fire escape access were obstructed.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Rios Recovery understands that fire escapes were obstructed due to furniture being in the way which causes serious concerns in case of an emergency. Bedroom furniture was either moved or removed from the bedroom to give full, straight forward access to the fire escapes.
Room checks will now be done daily by the house's team leader, so no furniture is added or moved by any resident and to make sure nothing is blocking the way to the fire escape.
A group message was sent out to all the residents by the house manager reiterating that no furniture or objects are allowed to be blocking the fire escapes path. This was also reiterated at the recovery house meeting on July 6th, 2025, by the house manager.
Furniture and obstructions were moved, and plan of correction was implemented on July 1st 2025 |
§ 717.30(d)(2) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen in addition to the fire extinguishers required under paragraph (1) . The extinguisher in the kitchen must be located near an exit and away from the cooking area.
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Observations
Based on review of the physical plant inspection the recovery house failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen in addition to the fire extinguishers required under paragraph (1) . The extinguisher in the kitchen must be located near an exit and away from the cooking area.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of 06/02/2025, the house manager and staff made sure a fire extinguisher was added to the recovery house's kitchen on the wall across from the stove. There are now two fire extinguishers on the first floor of the home.
The house manager and staff will make sure to triple check the annual check list for renewal and go over DDAP's regulations so that no fire extinguishers or other requirements are missed. |