INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, QIR26701 Fellowship House was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertain Recovery House licensing. 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)(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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Staff identified in need of infectious disease trainings have registered to complete the required training with DDAP on 9/23/26 & 9/24/26.House manager and Compliance/HR Director will ensure newly hired staff obtain the required trainings with the first 90 days of hire. |
§ 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 the record review the recovery house failed to 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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager and Compliance re-educated house staff on the regulation 8/7/26. Staff will ensure EC is notified and documentation of the notification will be documented in the client's record according to the regulation timeframe. |