INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection M29H6701 Transition in 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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§ 717.22(b)(3)(iv) 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:
(3) Basic personal data including:
(iv) Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker, and other medical conditions that the resident chooses to have in the house record.
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Observations
Based on review of the resident records, the recovery house failed to have the basic personal data including: Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker, and other medical conditions that the resident chooses to have in the house record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
12/05/2025 Created a separate medical information page that includes
Name of PCP
Address
Phone Number
Medication list of all medications the resident will be utilizing while residing at Transitions In Recovery
List of Medical conditions
Acid Reflux Y N Diabetes Y N
Allergies. Y N High Blood Pressure Y N
Pacemaker Y N Seizure Disorder Y N
Are there any other allergies or other medical conditions that we need to know about?
Signature lines will include the following @ bottom
Resident Name Date Resident Signature
Staff Witness Date Staff Witness Signature
House Manager will be responsible to insure this is accomplished 12/05/2025 |
§ 717.25(a)(1) LICENSURE Financial transactions
§ 717.25. Financial transactions.
(a) The licensee shall develop and implement written policies and procedures to maintain a complete record of collection of fees, payments and deposits between the licensee, the drug and alcohol recovery house or its employees and the resident or on behalf of the resident in accordance with standard accounting practices. The record must include:
(1) All fee deposits, resident fees and other monetary transactions between the drug and alcohol recovery house and the resident.
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Observations
Based on review of the resident records the recovery house failed to provide any documentation of all fee deposits, resident fees and other monetary transactions between the drug and alcohol recovery house and the resident.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
We will complete the resident roster and send in prior to the inspection date.
when we receive a list of residents needing their financial information done we will print out the information and have it ready for review during the physical inspection
Director will be responsible to insure this is accomplished.
11/28/2025
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§ 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 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.
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Plan of Correction
12/05/2025 Created an updated Consent to Residency Form that includes the following
Resident Consent to Treatment
Resident Rights
Emergency Contact Information
which identifies at time of admission the Family Member resident wants to be involved in their services and anyone else they wish to identify as an emergency contact.
Policy for TIR is to notify the resident's emergency contact within 12 hours of the following (providing proper consent is available)
1 Hospitalization of resident
2 Death of resident
3 Resident decision to end residency* (this includes return to use)
4 Failure of resident to return to house as expected*
Name Relationship Phone Number
Notification occurred on Date
This was completed by _____ at time: ______ am/pm Person spoken with yes/no
able to leave message yes/no
Reason for notification ___________________
House Manager will be responsible to insure this is accomplished 12/05/2025 |