INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 21, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 2QCT6701 TKO Rental Properties Supportive Housing 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(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.
|
Observations
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.
Findings: The personnel file was not available at time of renewal.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
- Correction: Rob's HIV/AIDS certificate, training plan, and evaluations have been submitted by the deadline.
- Prevention: A digital training file will be created for each staff member with a checklist for required documents.
- Responsible Party: House Manager
- Completion Date: October 29, 2025
- Timeframe: Immediate
- Thoroughness: Applies to Rob and will be extended to all staff.
Reg. 717.17(c)(1?5) ? Missing Personnel Record
- Correction: The personnel file will be compiled and submitted, including background check, resume, job description, and training certificates.
- Prevention: A hiring checklist will be implemented to ensure all documents are collected before start date.
- Responsible Party: House Manager
- Completion Date: October 29, 2025
- Timeframe: Immediate
- Thoroughness: Applies to the cited staff member; all other files will be reviewed.
|
? 717.22(b) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
(2) Resident orientation to the drug and alcohol recovery house which must include all of the following:
(i) Drug and alcohol recovery house rules, including a method to record residents ' expected return time to the drug and alcohol recovery house.
(ii) Fee schedule including any lease agreement.
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
(iv) Financial policies and procedures.
(v) The location of posted emergency procedures and contact information for the house manager and the Department.
(vi) Medication control and self-administration policies.
(3) Basic personal data including:
(i) Name.
(ii) Birth date.
(iii) Demographic information.
(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.
(v) Drug and alcohol history.
(vi) Medical contact information.
(vii) Emergency contact.
(4) Consent to residency.
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
|
Observations
Based on review of the resident records, the recovery house failed to have a full basic personal data form in resident records.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Reg. 717.22(b)(3)(i?vii) ? Missing Basic Personal Data
- Correction: All resident charts have been audited. Missing intake forms have been completed where possible or noted as unavailable for discharged clients.
- Prevention: Intake packets will be revised to include a mandatory checklist for personal data fields.
- Responsible Party: House Manager
- Completion Date: October 29, 2025
- Timeframe: 7 business days
- Thoroughness: Applies to all current residents; discharged charts will be annotated accordingly.
|
§ 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 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.
|
Plan of Correction
Reg. 717.22(b)(1) ? No Documentation of Unsuccessful Discharge Reason
- Correction: Discharge summaries for all residents discharged in the past 60 days have been reviewed and updated to include reasons for discharge.
- Prevention: A discharge checklist will be implemented requiring documentation of discharge reason and resident acknowledgment.
- Responsible Party: House Manager
- Completion Date: October 29, 2025
- Timeframe: 5 business days
- Thoroughness: Applies to all discharges post-inspection; prior discharges will be noted as unavailable.
|
§ 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 the physical plant inspection the recovery house failed to maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
Findings:
The bedroom window with the fire escape ladder was obstructed and inaccessible.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Bedrooms Must Be Unlocked During DDAP Visits
- Correction: Staff have been instructed to ensure all bedrooms remain unlocked during inspections.
- Prevention: A policy memo was issued and reviewed with house staff.
- Responsible Party: House Manager
- Completion Date: October 29, 2025
- Timeframe: Immediate
- Thoroughness: Applies to all future inspections.
8. Reg. 717.30(b)(2) ? Obstructed Fire Escape
- Correction: TKO Recovery House spoke directly with the neighboring property owner, who agreed to remove all items obstructing the shared fire escape. The neighbor has confirmed that the fire escape will remain clear and accessible at all times.
- Prevention: The House Manager will conduct monthly visual checks to ensure the fire escape remains unobstructed and will document each inspection.
- Responsible Party: House Manager
- Completion Date: October 29, 2025
- Timeframe: Immediate
- Thoroughness: Applies to the third-floor fire escape at 1302 State St.
9. Reg. 717.30(d)(2)(3) ? Expired and Hidden Fire Extinguisher
- Correction: The expired extinguisher has been replaced and relocated to a visible, accessible location.
- Prevention: Quarterly fire safety audits will be implemented.
- Responsible Party: House Manager
- Completion Date: October 29, 2025
- Timeframe: Immediate
- Thoroughness: Applies to all extinguishers in the facility.
PHYSICAL PLANT ? 6TH STREET
10. Reg. 717.30(b)(4) ? No Exit Sign
- Correction: An illuminated exit sign has been installed at the required location.
- Prevention: A full safety signage audit will be conducted quarterly.
- Responsible Party: House Manager
- Completion Date: October 29, 2025
- Timeframe: 3 business days
- Thoroughness: Applies to 6th Street location only.
11. Reg. 717.29(f)(4) ? Food Left Outside Resident's Door
- Correction: The food was immediately removed and the resident was counseled on house rules.
- Prevention: House rules will be re-posted and reviewed during weekly house meetings.
- Responsible Party: House Manager
- Completion Date: October 29, 2025
- Timeframe: Immediate
- Thoroughness: Applies to all residents at 6th Street.
|