INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 2, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, D6X16701 Guardian Angel 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.
|
Plan of Correction
|
§ 717.19(b) LICENSURE Resident Rights
§ 717.19. Resident rights.
(b) The licensee shall obtain written acknowledgement by residents that they have received notice of their rights.
|
Observations
Based on review of the resident records the recovery house failed to have written acknowledgement by residents that they have received notice of their rights.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Plan of Correction ? § 717.19(b), Resident Rights
All current resident records were reviewed on 7/2/2026 and each file contains a signed acknowledgment confirming receipt of resident rights. Going forward, the resident-rights acknowledgment will be included on the required admission-document checklist. Each new resident will receive a copy of her rights and sign the acknowledgment during admission. The Owner/Director will review resident files monthly to ensure continued compliance. |
§ 717.22(b)(4) 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:
(4) Consent to residency.
|
Observations
Based on a review of the resident records the recovery house failed to have a consent to residency signed within 24 hours of arrival.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Plan of Correction ? § 717.22(b)(4), Consent to Residency
All current resident records were reviewed 7/2/2026. To ensure each file contains a signed consent-to-residency form. Going forward, the form will be included on the required admission-document checklist and signed by each resident within 24 hours of arrival. The Owner/Director will verify completion within the required timeframe and review resident files monthly to ensure continued compliance. |
§ 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.
|
Observations
Based on a review of resident records, the recovery house failed to provide a written notification to the resident stating the decision to end residency and the timeframe for ending residency.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Plan of Correction ? § 717.23, Notification of Decision to End Residency
Records reviewed 7/2/2026. A standardized written notification form will be used whenever Guardian Angel Recovery House decides to end a resident's residency. The notice will state the reason for the decision, the effective date and timeframe for ending residency, and the resident's opportunity to request reconsideration before the decision takes effect. A copy of the written notice will be maintained in the resident's record. The Owner/Director will review all discharge documentation and conduct monthly record reviews to ensure continued compliance. |
§ 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 make 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
Plan of Correction ? § 717.27, Notification to Emergency Contact
After the records were reviewed on7/2/2026 the emergency-contact notification procedure has been reviewed and updated. When a resident decides to end residency or fails to return as expected, at least one attempt will be made to notify the resident's approved emergency contact immediately and no later than 12 hours, provided the resident has given consent. The date, time, method, and outcome of each notification attempt will be documented in the resident's record. The Owner/Director will review applicable resident records monthly to ensure continued compliance. |