INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 8, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, ERUE701 Franklin 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.
|
Plan of Correction
|
? 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.
|
Observations
Based on discussion with the house manager there is not any evidence of the required annual 6 hours of training. These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
as of 5/12/2026
To maintain compliance with annual renewal requirements, franklin recovery will ensure that the house managers will complete a minimum of (6) hours of required training by the month of June each calendar year. |
§ 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 provide a personnel file 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. These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
As of 5/12/2026
As of 5/12/26 the house manager will maintain a personnel file for each staff, volunteer,
or resident who is compensated in any form. The file will contain a PA State Police
criminal history record check, any disciplinary actions, a written job description, and
documentation of trainings. The documents for training will be the certificates of
required attended trainings such as HIV/AIDS, TB/STD, CPR, First Aid, fire prevention,
and emergency preparedness including use of fire extinguishers. Each training will be
accompanied in the record with an evaluation of the training, a training plan and plan for
addressing those needs. |
§ 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
The recovery house did not provide the requested documentation for staff volunteers assessment of training needs for each staff person and volunteer, a plan for addressing those needs, and a mechanism to collect feedback on completed training. These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
as of 5/12/2026
Franklin recovery acknowledges and has implemented a Resident Roster that contains all requested information in compliance with the program standards, and will be maintained by house manager/staff member. |
§ 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.
|
Observations
Based on the request for staff training records the recovery house failed to provide proof of required trainings for staff and volunteer .These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
On May 6, 2026, all training requirements will be maintained in the personnel file which will include training plan, plan for addressing those needs, and a mechanism to collect feedback. The house manager or appointed staff will be responsible to ensure that these documents are maintained so that this does not recur. It is the house managers responsibility to ensure that all documents are in the record. |
§ 717.21(a) LICENSURE Resident Roster
§ 717.21. Resident roster.
(a) The licensee shall maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
|
Observations
Based on review of the resident records the recovery house failed to have a resident roster that includes admission and discharge dates.These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
a resident roster has been implemented on 5/6/26. It will be maintained by the house manager or staff member appointed by the house manager. It will contain the resident name, admission date, discharge date. This roster will be maintained by the house manager or appointed staff member. The house manager is responsible for ensuring this does not recur. |
§ 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.
|
Observations
Based on a review of resident records, the recovery house failed to provide infomration that at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) 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.These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
As of May 6, 2026, notifications to family emergency has been occurring for any resident
who is unsuccessfully discharged from the recovery house. It is being documented in
the record with the date and time of contact. The house manager is responsible for
making the call and documentation of the call. The house manager will ensure that this
does not recur |
§ 717.29(g)(2) LICENSURE Physical plant standards - Heating-Cooling
§ 717.29. Physical plant standards.
(g) Heating and cooling. The licensee:
(2) May not use or permit portable space heaters.
|
Observations
Based on physical plant inspection the recovery house had sapce heaters. These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
On April 8, 2026, it was noticed that there were space heaters in bedrooms. All space heaters
were removed that day, and all residents have been informed that space heaters are not
permitted. The house manager will ensure that there are no space heaters going forward by
room checks. |
§ 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 physical plant inspection the recovery house did not ensure fire extinguishers were 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
as of May 6, 2026, all fire extinguishers have been inspected. The house manager is responsible to ensure this does not happen again by scheduling yearly fire extinguishers inspections by the local fire company. |