INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, TWMG6701 Franklin Recovery Etting 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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? 717.15(c) LICENSURE House Manager
§ 717.15. House Manager.
(c) The house manager shall complete at least 6 hours of training in one or more of the following areas within 6 months of becoming house manager, and annually thereafter:
(1) Fiscal policy.
(2) Administration.
(3) Program planning.
(4) Quality assurance.
(5) Program licensure.
(6) Personnel management.
(7) Confidentiality.
(8) Ethics.
(9) Trends in drug use and misuse.
(10) Developmental psychology.
(11) Interaction of addiction and mental illness.
(12) Cultural awareness.
(13) Sexual harassment.
(14) Relapse prevention.
(15) Substance use disorders.
(16) Peer support or mutual aid groups.
(17) Best practices for medication control and self-administration.
(18) Infection control.
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Observations
The house manager shall complete at least 6 hours of training annually was not complete. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of 5/6/26 the house manager will schedule the annual 6-hour training in preparation for the next renewal. For this deficiency to not recur the House Manager will complete the 6-hour annual training requirement by June of each year. The training will be in anything that is related to position, substance use disorder, or any other topic related to the operation of the recovery house or the population served. The house manager is responsible for this. " |
§ 717.17(c) LICENSURE Personnel Management
§ 717.17. Personnel management.
(c) The licensee shall maintain a personnel record for the house manager and each staff person and volunteer, which must include:
(1) Application or resume.
(2) A Pennsylvania State Police criminal history record check.
(3) Disciplinary actions.
(4) A written job description for each drug and alcohol recovery house position.
(5) Documentation of training.
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Observations
Based on review of the staff records the recovery house failed to provide a personnel file Application or resume. (2) A Pennsylvania State Police criminal history record check. (3) Disciplinary actions. (4) A written job description for each drug and alcohol recovery house position. (5) Documentation of training. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
? As of 5/12/26 the house manager will maintain a personnel file for each staff, volunteer, or resident who is compensated in any form. The file will contain a PA State Police criminal history record check, any disciplinary actions, a written job description, and documentation of trainings. The documents for training will be the certificates of required attended trainings such as HIV/AIDS, TB/STD, CPR, First Aid, fire prevention, and emergency preparedness including use of fire extinguishers. Each training will be accompanied in the record with an evaluation of the training, a training plan and plan for addressing those needs.
For resident roster citation ? a resident roster has been implemented on 5/6/26. It will be maintained by the house manager or staff member appointed by the house manager. It will contain the resident name, admission date, discharge date. This roster will be maintained by the house manager or appointed staff member. The house manager is responsible for ensuring this does not recur.
For notification of decision to end residency citation ? a written notification of decision to end residency has been incorporated as of 5/6/26. Going forward the notification will be presented to the resident at time of discharge in any event that is unsuccessful. The resident will have time to appeal and sign the document. If the resident does not sign the document, it will be noted as refused on the form. Forms will be maintained in the resident record. The house manager is responsible to monitor that the forms are being used by checking discharge records as they occur and to ensure that this does not recur.
For notification to family emergency or emergency contact citation ? As of May 6, 2026, notification to family emergency has been occurring for any resident who is unsuccessfully discharged from the recovery house. It is being documented in the record with the date and time of contact. The house manager is responsible for making the call and documentation of the call. The house manager will ensure that this does not recur.
For safety and emergency procedures (fire extinguishers) ? as of May 6, 2026, all fire extinguishers have been inspected. The house manager is responsible to ensure this does not happen again by scheduling yearly fire extinguishers inspections by the local fire company.
For Franklin Recovery you can use the same POC information where it will apply
For the areas that are different citations at the recovery house.
Training ? On May 6, 2026, all training requirements will be maintained in the personnel file which will include training plan, plan for addressing those needs, and a mechanism to collect feedback. The house manager or appointed staff will be responsible to ensure that these documents are maintained so that this does not recur. It is the house managers responsibility to ensure that all documents are in the record.
Training 2 The documents for training will be the certificates of required attended trainings such as HIV/AIDS, TB/STD, CPR, First Aid, fire prevention, and emergency preparedness including use of fire extinguishers. Each training will be accompanied in the record with an evaluation of the training, a training plan and plan for addressing those needs.
Physical plant citation ? On April 8, 2026, it was noticed that there were space heaters in bedrooms. All space heaters were removed that day, and all residents have been informed that space heaters are not permitted. The house manager will ensure that there are no space heaters going forward by room checks.
If you have any questions, please do not hesitate to reach out.
Thank you,
Antoinette Sacco | Recovery House Licensing Specialist
Pennsylvania Department of Drug and Alcohol Programs
Bureau of Program Licensure
Division of Licensing Operations
Recovery House Licensure
One Penn Center
2601 N. 3rd Street, 5th Floor | Harrisburg, PA 17110
717-783-8675
Andre Defrancesco
May 15, 2026, 9:07 AM (4 days ago)
to Antoinette, Harlando
I can tell you this Miss Sacco. Once these changes are corrected and everything is in accordance, I will understand it and be able to complete this all going forward. This is the first time in the 3 years that we are fully aware of these stips and already it is helping us at Frankllin Recovery. We are getting more balanced and efficient. More organization also! I am sorry about the documents. This will be corrected all within a day or two! I apologize. Food for thought. We had a dog pass and had to put her down, my wife's close friend at 38 died of cancer and someone crashed into our car while we was asleep all the last 5 days! We will prioritize this in next few days. Also the ladder for the exit arrived. (Will send your the photo). Thanks again Miss Sacco! I will say a prayer to St Joseph this weekend when I am at the annual Italian Festival for both of us at the 9th street Market
Andre Defrancesco -Owner and Operator of Franklin Recovery Intake and Sober living homes 215-501-9461
Sacco, Antoinette
Attachments
May 15, 2026, 10:04 AM (4 days ago)
to me, Harlando
Good morning.
Andre, I fully understand that this is a learning lesson. As I have always stated this is a collaboration. Recognizing that this is your first time for citations I have written plan of corrections so that you can learn what is being asked when writing a plan of correction. On May 6 I sent an email with that had everything you need and covering all the points that are needed. I am adding the language to the attached document so you can drop and paste into the POC if that is what you wish to do. It will alleviate the stress of having to create anything and they will be correct. Please see the attached document. Read the citation and then answer in the system with the verbiage.
I am so sorry to hear about the string of events that have occurred.
As always, if you have any questions, please feel free to reach out.
Thank you,
Training ? Starting on May 6, 2026, all training requirements will be maintained in the personnel file which will include training plan, plan for addressing those needs, and a mechanism to collect feedback. The house manager or appointed staff will be responsible to ensure that these documents are maintained so that this does not recur. It is the house managers responsibility to ensure that all documents are in the record.
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Harlando Matthews
Attachments
May 18, 2026, 11:59 AM (1 day ago)
to me
Copy and paste, she did it for you already in this attachment
From: Sacco, Antoinette
Sent: Friday, May 15, 2026 10:04 AM
One attachment
- Scanned by Gmail
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§ 717.21(a) LICENSURE Resident Roster
§ 717.21. Resident roster.
(a) The licensee shall maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
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Observations
Based on review of the resident records the recovery house failed to have a resident roster.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
a resident roster has been implemented on 5/6/26. It will be maintained by the house manager or staff member appointed by the house manager. It will contain the resident name, admission date, discharge date. This roster will be maintained by the house manager or appointed staff member. The house manager is responsible for ensuring this does not recur. |
§ 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 notification to the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency, an opportunity to request reconsideration. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
a written notification of decision to end residency has been incorporated as of 5/6/26. Going forward the notification will be presented to the resident at time of discharge in any event that is unsuccessful. The resident will have time to appeal and sign the document. If the resident does not sign the document, it will be noted as refused on the form. Forms will be maintained in the resident record. The house manager is responsible to monitor that the forms are being used by checking discharge records as they occur and to ensure that this does not recur. |
§ 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 document 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
As of May 6, 2026, notification to family emergency has been occurring for any resident who is unsuccessfully discharged from the recovery house. It is being documented in the record with the date and time of contact. The house manager is responsible for making the call and documentation of the call. The house manager will ensure that this does not recur. |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
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Observations
Based on the physical plant inspection the recovery house failed to have annually inspected fire extinguishers. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
as of May 6, 2026, all fire extinguishers have been inspected. The house manager is responsible to ensure this does not happen again by scheduling yearly fire extinguishers inspections by the local fire company.
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