INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, JDTI6701 The Pocket 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)(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, the facility failed to provide documentation of all staff persons and volunteers to complete HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum within 90 days of hire.
Staff #1 was hired on 10/10/25 and was still in this position at the time of the inspection. There was no documentation of HIV/AIDS training using a department approved curriculum within 90 days of hire.
Staff #2 was hired on 11/10/25 and was still in this position at the time of the inspection. There was no documentation of HIV/AIDS and tuberculosis and sexually transmitted diseases training using a department approved curriculum within 90 days of hire.
Staff #3 was hired on 2/13/26 and was still in this position at the time of the inspection. There was no documentation of HIV/AIDS training using a department approved curriculum within 90 days of hire.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The facility acknowledges that documentation of the required HIV/AIDS, tuberculosis, and sexually transmitted disease trainings was not completed and maintained within 90 days of hire for the identified staff members.
Staff #1 and Staff #2 completed all required trainings using a Department-approved curriculum on August 6, 2026. Their training certificates have been placed in their personnel files. Staff #3 is no longer employed by the facility; therefore, no further corrective action applies to that individual.
HR/Compliance has continuously monitored staff training requirements and regularly informed the Facility Director and staff supervisors of outstanding trainings, upcoming deadlines, and the importance of timely completion to maintain DDAP compliance. Moving forward, the Facility Director and staff supervisors will be responsible for ensuring that employees complete all assigned trainings by the required deadlines, while HR/Compliance will continue to track completion and provide reminders.
Effective July 8, 2026, the facility strengthened its training tracking process to identify each employee's hire date, required trainings, 90-day deadline, completion date, and supporting documentation. HR/Compliance will conduct monthly personnel-file and training audits for six months and quarterly audits thereafter. Any identified deficiency will be immediately reported to the Facility Director and appropriate supervisor for correction.
Completion Date: All corrective actions were completed as of August 6, 2026. |
§ 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 review of discharged resident records the facility failed to notfy the emergency contact in one out of 3 unsuccessful discharge records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The facility acknowledges that the emergency contact was not notified in one of the three unsuccessful discharge records reviewed. Upon identification of this deficiency, the facility reviewed its discharge procedures with recovery house staff and reinforced the requirement that the resident's authorized emergency contact be notified following an unsuccessful discharge, when clinically appropriate and permitted by the resident's written consent and applicable confidentiality requirements.
Effective August 7, 2026, the facility implemented a discharge checklist requiring staff to document the date, time, method, and outcome of the emergency-contact notification. If notification cannot be completed or is prohibited due to the absence of valid consent, staff must document the reason in the resident's discharge record. A supervisor will review and sign the checklist to confirm that all required discharge notifications and documentation have been completed.
The Facility Director or designee will review all unsuccessful discharge records monthly for six months to verify compliance. Any deficiency identified during these reviews will be addressed immediately through staff education and corrective follow-up.
Completion Date: All corrective actions, including staff education and implementation of the revised discharge checklist, were completed by July 28, 2026. |