INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, D2476701 Cold Bore Recovery 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(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
Baased on review of personnel files the recovery house failed to have staff completion of the trainings that are required within 90 days.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.18(c)(2) ? Training
All applicable personnel files have been reviewed to verify completion of first aid training, including overdose reversal medication training.
Any staff person or volunteer who has not completed the required training will be scheduled to complete the training by July 10, 2026. Staff who have not completed the required training will be tracked by the Operations Manager until documentation of completion is received and placed in the personnel file.
Going forward, the Operations Manager will track each employee's and volunteer's start date and required training deadlines to ensure completion within 90 days. The Executive Director will verify compliance through quarterly personnel file audits.
Persons Responsible: Operations Manager and Executive Director
Date of Full Compliance: July 10, 2026 |
§ 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 review of the resident records the recovery house failed to have residents sign document within 24 hours stating that they have been made aware of resident orientation to the recovery house including house rules.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
§ 717.22(b)(2)(i) ? Beginning of Residency
Effective June 22, 2026, the House Manager or designated admission staff will review the recovery house rules and the method for recording expected return times with each new resident and obtain the resident's signed acknowledgment within 24 hours of arrival.
The Operations Manager will train applicable staff on this requirement by June 26, 2026. The House Manager will review each new resident file within 24 hours of admission to confirm the signed documentation is complete. The Operations Manager will conduct monthly file reviews and provide corrective training when necessary to maintain ongoing compliance.
Persons Responsible: House Manager and Operations Manager
Date of Full Compliance: June 26, 2026 |