INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 6QYW6701 Soulvation Farms 2 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 review of the staff records the recovery house failed to have staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer: HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In response, the case manager has issued a training plan to the house manager including the HIV training and the TB/STD training. House manager will have both trainings completed by 10/31/25. Going forward the case manager will ensure that all new employees and volunteers have taken this training or will take this training within 90 days of hire. Case manager will monitor and modify training for all employees and volunteers ongoing. |
§ 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.
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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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
With regards to the second citation, we have changed our procedure to include an administrative discharge form for any resident who leaves prior to their successful discharge date. This document will have more detail about the circumstances surrounding the resident's discharge. This document will be used for residents who leave against medical advice, are administratively discharged, or have left for some other reason such as being incarcerated. This correction was implemented IMMEDIATELY (10/19/2025). For current residents and clients new to the facility and ongoing, the CASE MANAGER will be responsible for ensuring that any resident who discharges in any manner other than successful will have one of these forms in their record and one to keep themselves if possible. CASE MANAGER has already implemented this procedure (10/19/2025) and will be responsible for said documents ongoing. |