INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection G0B96701 C And A Recovery Solutions 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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§ 717.18(c)(1) 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:
(1) Cardiopulmonary resuscitation (CPR) certification.
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Observations
Based on a review of staff records, the recovery house failed to complete CPR training using a department approved curriculum training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
house manager will complete CPR training again with induvial certificate by 12/01/2026. Certificate will be placed in house manager training folder. |
§ 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 recovery house failed to complete First aid training, including training on overdose reversal medication using a department approved curriculum training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
house manager will complete first aid training by 12/01/2026. this training will include its own separate certificate and will be placed in the house manager training folder to update the files. |
§ 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 recovery house failed to complete HIV/AIDS, TB/STD training using a department approved curriculum training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
house manager will complete training by 02/14/2026. the completed training certificate will be placed in the updated house manager files. |
§ 717.18(c)(4) 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:
(4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
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Observations
Based on a review of staff records, the recovery house failed to complete Fire prevention and emergency preparedness, including use of a fire extinguisher using a department approved curriculum training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
house manager has completed training prior to 01/11/2026 for the fire safety and emergency preparedness, and the file will be placed in the updated house manager training file. |
§ 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 a review of resident records, the recovery house failed to provide any discharge records in order to determine if written notification was given to the resident to end residency, if an opportunity to request the licensee reconsider to end residency was provided or if resident decided to end residency without providing a reason to the licensee.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
house manager has begun the process of documentation of the physical files of every residence. this process started taking place on 12/10/2026. written documentation of all notifications to end residency will be kept with every induvial file |
§ 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 make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) 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
In all resident discharge files reviewed, the recovery house failed to notify the emergency contact within 12 hours of resident ' s departure.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
house manager started physical documentation on 12/10/2026 for every discharge and emergency contact made for each induvial discharged. all documentation will be kept in the client's individual file |