INITIAL COMMENTS
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This report is a result of a renewal on-site licensure inspection conducted on July 23, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 9QDF6701 Transitioning Lives Llc. was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
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Plan of Correction
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? 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 the house manager ' s records, the facility failed to provide documentation of at least six hours of annual training being completed by the house manager.
Staff #1 was hired as the house manager on January 1, 2024, and was still in this position at the time of the inspection. There was no documentation of six hours annual training completed.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager completed CPR training on July 24th and the certificate will be uploaded.
scheduled for Eight hours of additional training will be scheduled within the next 60 days, which includes HIV/TB and ethics
House manager will review the training plan every 6 month July 31 and January 30.
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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 a review of staff records, the facility failed to provide documentation of the signed and dated individual training plan.
Staff #1 was hired as the house manager on January 1, 2024, and was still in this position at the time of the inspection. There was no documentation provided on a training plan.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Following inspection. House manager completed upcomimg training for the year. House Manager documented current scheduled training hrs.
House Manager is responsible for maintaining records and maintaining them in a secure area. Training plans documentation will occur for 6 month reviews in January. |
§ 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 facility failed to provide documentation for all staff persons and volunteers to complete Cardiopulmonary resuscitation (CPR) certification training using a department approved curriculum within 90 days of hire.
Staff #1 was hired as the house manager on January 1, 2024, and was still in this position at the time of the inspection. There was no documentation of CPR being completed 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
Following inspection House Manager obtained CPR certification with 2 years re-certification required.
House Manager will utilize training plan review to assure re-certification in the completed in time period designated from initial certification date.
House Manager is responsible to report completion to DDAP to maintain ongoing compliance. |
§ 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 facility failed to provide documentation for all staff persons and volunteers to complete first aid training, including training on overdose reversal medication using a department approved curriculum within 90 days of hire.
Staff #1 was hired as the house manager on January 1, 2024, and was still in this position at the time of the inspection. There was no documentation of first aid training, including training on overdose reversal medication being completed 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
House Manager has completed overdosed reversal training with CPR trainer.
In the future House Manager will require all new hires and volunteer if needed to complete training plan at the beginning of hire date and require this training be complete at or before 90 probationary period.
This will be documented according to New Hire pre-employment screening Packet
House Manager is responsible for 6 month training review to assure compliance. |
§ 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.
Staff #1 was hired as the house manager on January 1, 2024, and was still in this position at the time of the inspection. There was no documentation on HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum being completed.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager is currently on waiting list scheduled for HIV/AIDS and turberlosis and sexually transmitted diseases training from DDAP approved curriculum
House Manger will require any new staff and volunteers hire to complete above training within 60 days of hire/start date.
House Manager obtained DDAP access to training management system and will require new hires to apply
Training plan log will be created and updated to assure compliance. |
§ 717.22(b)(2)(i) 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:
(i) Drug and alcohol recovery house rules, including a method to record residents' expected return time to the drug and alcohol recovery house.
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Observations
Based on eight resident records reviewed, the facility failed to include a method to record residents ' expected return time to the drug and alcohol recovery house.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager created a standardized Resident Sign-out/Return Log that has been created to document the expected return time for all residents when living in the facility.
House manager will review daily to verify accuracy and completeness by signing initials.
All Residents will receive orientation by the house manager on the new procedure to assure compliance and accountability |
§ 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 four discharged resident records reviewed, the facility failed to provide written notification to the residents stating the decision to end residency. The facility was not completing documentation to end residency and the reasons for residency ending.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager has developed
Discharge Notification Form created for the discharge, the effective date, and the residents right to appeal or seek clarification.
House Manager will receive written notification at the time of discharge with a copy placed in their resident file.
House Manager will conduct a monthly audit of discharged resident files to verify compliance and written notifications and documentation procedures. |
§ 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 four discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning 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 created
A resident discharge and Non-Return Notification Procedure requiring of a discharge decision or failure to return to Transitioning Lives
Form completed will verify notification of the residents listed emergency contact with-in 24 hours
1. Date and Time of Contact attempt
2. Name of emergency contact
3. Member making call
4. Outcome of call
House Manager will review and verify residents records weekly to verify emergency contacts were notified and documentation complete.
Copies of Notification will be retained in each residents file at Transitioning Lives |
§ 717.29(e)(3) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120°F.
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Observations
Based on a physical plant inspection, the facility failed to keep the water temperature from exceeding 120 degrees Fahrenheit. The water temperature in the bathroom was read at 139 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Following a plant inspection House Manager corrected temperature to 120 degrees.
A thermometer will be purchased and placed in the House Manager office.
House Manager created Spreadsheet to document weekly checks by the House Manager or attending volunteers if necessary.
House manager will require initial and signature and review monthly to maintain compliance. |