INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 26, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection E4G46701 Central Pennsylvania Recovery Associates, Llc 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
|
§ 717.17(b)(1) LICENSURE Personnel Management
§ 717.17. Personnel management.
(b) The written policies and procedures must include:
(1) Use of volunteers.
|
Observations
Based on five resident records reviewed, the facility failed to provide documentation, signed by the resident, disclosing the criteria for beginning and ending residency.
These findings were reviewed with the recovery house staff during the licensing process
|
Plan of Correction
A beginning / ending of residency criteria form has been created and will be instituted by the house manager on all future intakes.
A paragraph being more descriptive has been added to the handbook as well.
The house manager will make sure that this occurs on every intake. This correction has already taken place. The house manager and owner will review all resident records quarterly to ensure 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 three of three discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.
Resident # 3 was admitted on July 10, 2025, and discharged March 4, 2026. There was no documentation of an end to residency in the resident record.
Resident # 4 was admitted on January 7, 2026, and discharged March 6, 2026. There was no documentation of an end to residency in the resident record.
Resident # 5 was admitted on March 29, 2025, and discharged December 31, 2025. There was no documentation of an end to residency in the resident record.
These findings were reviewed with the recovery house staff during the licensing process
|
Plan of Correction
The End of Residency form has been updated to include date and time exited along with date and time emergency contact has been notified. This form will be used on all future exits, successful or non-successful.
The house manager will make sure this occurs on every exit and the owner will review all records quarterly to assure compliance.
This will be audited quarterly by the owner to be assured this does not occur again. |
§ 717.29(e)(3) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120°F.
|
Observations
Based on a physical plant inspection, the facility failed to keep the water temperature from exceeding 120 degrees Fahrenheit. The bathroom had a water temperature of 133 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The temperature of the water heater for the residence has been decreased by the house manager and tested to be 112 degrees.
The house manager will test the water temperature weekly to assure this will not occur again. |
§ 717.30(b)(1) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(1) Ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed. The emergency exit on the second floor was obstructed and not easily accessible.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The second floor fire exit has the items blocking it moved, including the twin bed turned to where it was supposed to be.
This was done immediately after inspection by the house manager. The house manager will inspect this area weekly to be sure it does not happen again. |