INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 30, 2025 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 which pertain to the facility. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
|
Plan of Correction
|
§ 717.17(c) LICENSURE Personnel Management
§ 717.17. Personnel management.
(c) The licensee shall maintain a personnel record for the house manager and each staff person and volunteer, which must include:
(1) Application or resume.
(2) A Pennsylvania State Police criminal history record check.
(3) Disciplinary actions.
(4) A written job description for each drug and alcohol recovery house position.
(5) Documentation of training.
|
Observations
Based on review of the staff records the recovery house failed to have a Pennsylvania State Police criminal history record check for new employees available.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Human resources have completed PSP criminal history record check for all current employees as of 8.20.2025
It will be the responsibility of Human resources to complete PSP criminal history record check for all future employees
Human resources have updated hiring policies to include PSP criminal background checks for all employees at licensed sober house.
The CEO will be responsible for ensuring this policy is followed, the CEO will also be responsible to ensure Human resources completes background check for all new hires receive a background check. |
§ 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.
|
Observations
Based on review of the staff records the recovery house failed to have a mechanism to collect feedback on completed training.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Human resources implemented a post training survey on 8.20.2025 to receive satisfaction and feedback for training attended.
CEO will ensure Human resources collects and files the post training survey as part of employees HR record. |
§ 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.
|
Observations
Based on review of the staff records the recovery house failed to have the following trainings complete within 90 days of hire: HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Human resources will adhere to the hiring policy for mandatory training which include HIV/AIDS, tuberculosis and sexually transmitted diseases.
Human resources is responsible for tracking training on all employees and volunteers to ensure completion of training within 90 days of hire.
As of 8.23.2025 the employees that were missing training have either completed or are scheduled to complete the training. |
§ 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.
|
Observations
Based on review of the resident records the recovery house failed to provide residents with notification of criteria for beginning and ending residency and signature of residents receiving a copy of the orientation handbook within 24 hours of arrival .
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
House manager implemented policy on 8.20.2025 in which house manager is responsible for obtaining signatures of clients within 24 hours of admission after reviewing orientation handbook, house manager will upload signed receipt into EMR under residence tab.
Human resources is responsible for adding admission and discharge dates to residence tab in EMR.
Human resources is responsible for adding signature of orientation handbook to admission checklist which is completed by house manager.
CEO will audit EMR monthly to ensure all signatures are obtained and documented.
CEO will audit EMR monthly to ensure all admit and discharge dates are documented |
§ 717.22(b)(2)(ii) 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:
(ii) Fee schedule including any lease agreement.
|
Observations
Based on review of the resident records the recovery house failed to have a fee schedule including any lease agreement.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Human resources added on 8.20.2025 a promissory note to the residence tab in EMR in which house manager will complete with client upon admission.
CEO is responsible for ensuring the completion of promissory note in the EMR. |
§ 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.
|
Observations
Based on review of the physical plant the recovery house failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
House manager removed all obstructions from stairways, hallways, and exits from rooms on 8.20.2025.
Human Resources will add specific line to daily check of house to include obstructions in stairways, hallways and exits from rooms. |
§ 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.
|
Observations
Based on review of the physical plant the recovery house failed to ensure that a fire extinguisher with a minimum of an ABC rating in each kitchen.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
CEO contacted Cintas on 8.21.2025 to inspect service and install appropriate fire extinguers in kitchens at 1554 Sanderson Ave Scranton, PA and at 126 Willow Ave Olyphant, PA.
House manager will be responsible for ensuring fire extinguishers will remain in kitchen where they were installed.
Human resources updated the responsibilities of the house managers job description to include daily inspections with the specific line item of kitchen fire extinguishers. |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
|
Observations
Based on review of the physical plant the recovery house failed to ensure that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
CEO contacted Cintas on 8.21.2025 to schedule annual inspection for fire extinguishers.
House Manager will inform CEO 30 days prior to expiration of inspection of fire extguishers so CEO can schedule the inspection with Cintas.
Human Resources will update fire extinguisher policy and procedure to include monthly check of all fire extinguers to ensure working properly and inspection date. |