INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 7, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 02376701 ODAAT (One Day at a Time) 1 Recovery 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.
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Plan of Correction
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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 recovery house failed to provide an (1) 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. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.18(a) ? Staff Training Plan Requirements
Corrective Action Taken:
The facility will develop and implement a comprehensive Staff Training and Development Policy that includes:
- Individualized training needs assessments for all staff and volunteers
- Individual training plans based on role and identified needs
- A standardized training feedback form completed after each training
All current staff and volunteers will complete a retrospective training needs assessment and corresponding training plans.
Systemic Changes Implemented:
- A Training Needs Assessment Tool has been implemented on 4/15/2026 and added to all personnel files
- A Training Plan Template is now required upon hire and updated annually
- A Training Feedback Form is required after each training session and maintained in training records
Monitoring Plan:
- The Program Director/House Manager will review all staff training files monthly for compliance
- A Training Compliance Log will be maintained and reviewed during monthly meetings
- Any deficiencies will be corrected and available for next reveiw.
Responsible Staff: Program Director / House Manager
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§ 717.18(b) LICENSURE Training
§ 717.18. Training.
(b) The licensee shall conduct and document an evaluation of the training plan annually.
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Observations
Based on review of staffing records the facility failed to provide an evaluation of the training plan annually.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.18(b) ? Annual Evaluation of Training Plan
Corrective Action Taken:
An annual evaluation of the training program has been completed, assessing staff compliance, training effectiveness, and gaps.
Systemic Changes Implemented:
- An Annual Training Evaluation Tool has been developed and implemented on 4/15/2026
- The evaluation is now scheduled to occur every 12 months and includes review of all training records, staff feedback, and compliance rates
Monitoring Plan:
- The Program Director/House Manger will ensure annual review is completed and documented
- Documentation will be maintained in the file
- Compliance will be reviewed during annual licensing readiness audits
Responsible Staff: Program Director/House Manager
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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 review of the staff records the recovery house failed to provide proof of CPR training 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
§ 717.18(c)(1) ? CPR Certification
Corrective Action Taken:
All current staff will be scheduled for and/or completed CPR certification .
Systemic Changes Implemented on 4/08/2026
- CPR certification is now required within 90 days of hire and tracked via onboarding checklist
- Proof of certification is maintained in each personnel file
Monitoring Plan:
- House Manger/Program Director will track certification status using a Training Tracker Spreadsheet
- Monthly review of staff files to ensure compliance
Responsible Staff: Program Director / House Manager
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§ 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 review of the staff records the recovery house failed to provide evidence of first aid training, including training on overdose reversal medication. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.18(c)(2) ? First Aid & Overdose Reversal Training
Corrective Action Taken:
All staff have completed or will be scheduled for First Aid and Narcan/overdose reversal training.
Systemic Changes Implemented on 4/08/2026
- Required training added to onboarding process with 90-day deadline
- Partnerships established with certified trainers/providers if applicable
Monitoring Plan:
- Training completion tracked monthly
- Documentation maintained in personnel files and training log
Responsible Staff: Program Director/House Manager
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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 review of the staff records the recovery house failed to provide evidence of 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.
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Plan of Correction
§ 717.18(c)(3) ? HIV/AIDS, TB, STD Training
Corrective Action Taken:
All staff have completed or will be enrolled in Department-approved HIV/AIDS, TB, and STD training.
Systemic Changes Implemented on 04/08/2026
- Approved training sources identified and standardized
- Training added to onboarding checklist with 90-day requirement
Monitoring Plan:
- Monthly audit of training compliance
- Certificates maintained in personnel files
Responsible Staff: Program Director/House Manager
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§ 717.29(e)(5) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection the recovery house failed to maintain a operable exhaust fan or window. These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
§ 717.29(e)(5) ? Bathroom Ventilation
Corrective Action Taken:
All inoperable exhaust fans will be repaired or replaced once work order is approved on 5/30/2026
Systemic Changes Implemented on 5/15/2026
- Ventilation systems added to routine maintenance checklist
Monitoring Plan:
- Monthly inspection of all bathrooms
- Work orders documented and tracked
Responsible Staff: Maintenance / House Manager
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