INITIAL COMMENTS
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This report is a result of an renewal on-site licensure inspection conducted on March 10, 2026 through March 12, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, P05I6701 TNH Sober Living 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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§ 717.18(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, 1 out of 4 staff failed to complete CPR certification within 90 days of becoming staff.
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Plan of Correction
Prior to the inspection the Executive Director/House Manager created a Human Resources Documentation Tracker as an internal audit revealed that this Resident Lead's training records were out of date. The Tracker includes all required HR Records for DDAP, as well as conditional formatting to highlight when expected documents are missing and/or approaching an out-of-date status according to DDAP's requirements and internal TNH policy. Specific folders for each employee are maintained in TNH's SharePoint.
The Executive Director/House Manager utilizes the Tracker daily. A Managing Partner reviews the accuracy of the Tracker quarterly in terms of the records it reflects and to ensure there are no missing or out-of-date documents. These monitoring frequencies began prior to the survey by DDAP on 3/10/2026.
As these records were already out-of-date, no correction of the specific cited finding can be completed. |
§ 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, 1 out of 4 staff failed to complete first aid training, including training on overdose reversal medication within 90 days of becoming staff.
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Plan of Correction
Prior to the inspection the Executive Director/House Manager created a Human Resources Documentation Tracker as an internal audit revealed that this Resident Lead's training records were out of date. The Tracker includes all required HR Records for DDAP, as well as conditional formatting to highlight when expected documents are missing and/or approaching an out-of-date status according to DDAP's requirements and internal TNH policy. Specific folders for each employee are maintained in TNH's SharePoint.
The Executive Director/House Manager utilizes the Tracker daily. A Managing Partner reviews the accuracy of the Tracker quarterly in terms of the records it reflects and to ensure there are no missing or out-of-date documents. These monitoring frequencies began prior to the survey by DDAP on 3/10/2026.
As these records were already out-of-date, no correction of the specific cited finding can be completed. |
§ 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, 1 out of 4 staff failed to complete HIV/AIDs, tuberculosis and sexually transmitted diseases training within 90 days of becoming staff.
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Plan of Correction
Prior to the inspection the Executive Director/House Manager created a Human Resources Documentation Tracker as an internal audit revealed that this Resident Lead's training records were out of date. The Tracker includes all required HR Records for DDAP, as well as conditional formatting to highlight when expected documents are missing and/or approaching an out-of-date status according to DDAP's requirements and internal TNH policy. Specific folders for each employee are maintained in TNH's SharePoint.
The Executive Director/House Manager utilizes the Tracker daily. A Managing Partner reviews the accuracy of the Tracker quarterly in terms of the records it reflects and to ensure there are no missing or out-of-date documents. These monitoring frequencies began prior to the survey by DDAP on 3/10/2026.
As these records were already out-of-date, no correction of the specific cited finding can be completed. |