This report is a result of an on-site licensure renewal inspection conducted on September 16, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Sanctury House, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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Observations
Based on a review of fire drill logs from September 2025 through September 2026, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation for a fire drill occurring during the months of September 2025 through December 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.10 (d) (1) LICENSURE
Fire safety:
705.10. Fire safety. (d) Fire drills. The residential facility shall: (1) Conduct unannounced fire drills at least once a month.
Corrective Action Plan
Immediate Action:
Effective immediately, the Project Director has implemented a standardized system for the completion, review, and retention of fire drill documentation. The facility acknowledges that fire drill documentation for September 2025 through December 2025 was not available for review during the inspection. Although the facility believes it conducted the drills, the corresponding paper documentation was misfiled and could not be located before the inspection was completed. The facility recognizes that documentation must be readily accessible and available for verification.
A designated BHT staff member will maintain a centralized fire drill binder organized by calendar year (eliminating the folder). The staff member conducting the drill will complete and sign each monthly fire drill log, and the Project Director or designee will review it. Following completion and review, the documentation will be scanned into Sanctuary House's electronic record system, and the original document will be filed in the appropriate section of the fire drill binder.
The fire drill binder will be maintained in the locked closet located within the Project Director's office to ensure that documentation is secure, organized, and readily accessible for review. These corrective measures are being implemented to ensure compliance with Title 28 Pa. Code § 709 and the applicable requirements of Title 28, Part V, including requirements governing the maintenance and availability of required facility documentation.
Ongoing Compliance:
The Project Director or designee will verify monthly that the required fire drill documentation is current, properly completed, appropriately signed, and retained in both the electronic record and the designated fire drill binder. The binder will also be reviewed quarterly by the Project Director to verify that documentation is complete and filed according to calendar year.
Monitoring and Oversight:
The Project Director and Governing Body have reviewed the applicable DDAP regulations, licensing requirements, and Sanctuary House policies and procedures on fire drills and the maintenance of fire drill documentation, including Title 28 Pa. Code § 709 and applicable provisions of Title 28, Part V.
The Project Director will monitor compliance through monthly documentation checks and the quarterly review of the fire drill binder. Any identified deficiency will be addressed immediately, including review of the facility's fire drill schedule and procedures and correction of any documentation deficiency.
Prevention of Recurrence:
The implementation of a centralized, calendar-year fire drill binder, required electronic scanning, monthly verification, and quarterly supervisory review will provide multiple levels of oversight and reduce the risk of missing, misfiled, or incomplete fire drill documentation. These measures are intended to ensure that required fire drill documentation is completed, accurately maintained, readily accessible for review, and maintained in accordance with Title 28 Pa. Code § 709 and applicable requirements of Title 28, Part V.
Person Responsible for Implementation:
Project Director
Completion Date:
Effective immediately, 10/05/2026, and ongoing.
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