INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection IZ1W6701 Stop & Surrender Wayne Ministries Rainbow 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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§ 717.17(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 a review of personnel records, the facility failed to provide a complete personnel record for employees 1, and 4, that 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.
Employee # 1 was hired on May 5, 2025, and was still employed at the time of the inspection. There was not a criminal history check or job description documented.
Employee # 4 was hired on March 16, 2026, and was still employed at the time of the inspection. There was not an application or resume, criminal history check, or job description documented.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
POC
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) 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.
Before hiring, all new staff shall provide a resume. The HR staff or the hiring staff will ensure the new hire has or/and completed the following: (1) filled out an application, (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, before the official start of work.
All documents must be completed upon hiring or within the days of training to complete the hire process for personnel records and to give to the HR staff or Director. Failure to provide the following documentation can affect the hiring decision.
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§ 717.18(c)(4) 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:
(4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
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Observations
Based on a review of personnel records, the facility failed to provide documentation for all staff persons and volunteers to complete the following within 90 days of becoming an employee or volunteer:
(1) Cardiopulmonary resuscitation (CPR) certification.
(2) First aid training, including training on overdose reversal
medication.
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training
using a department approved curriculum.
(4) Fire prevention and emergency preparedness, including use of a fire
extinguisher.
Employee # 3 was hired on January 5, 2026, and was still employed at the time of the inspection. There was no documentation the required training provided.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
POC
717.18 Training. (a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of all of the following: (1) An assessment of training needs for each staff person and volunteer. (2) A plan for addressing those needs. (3) A mechanism to collect feedback on completed training. (b) The licensee shall conduct and document an evaluation of the training plan annually. (c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete all of the following within 90 days of becoming an employee or volunteer: (1) Cardiopulmonary resuscitation (CPR) certification. (2) First Aid training, including training on overdose reversal medication. (3) HIV/ AIDS, tuberculosis, and sexually transmitted diseases training using a Department-approved curriculum. (4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
Upon hiring, all new staff and volunteers are provided with a list of required training and completion deadlines. The HR staff will ensure the new hire has or/and completed the following within the 90 days of hire:
(1) Cardiopulmonary resuscitation (CPR) certification.
(2) First Aid training, including training on overdose reversal medication.
(3) HIV/ AIDS, tuberculosis, and sexually transmitted diseases training using a Department-approved curriculum.
(4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
All documents must be completed within 90 days of hire. After all the training is complete, HR will provide a data collection form for feedback to be added to personnel records. Failure to complete the following trainings can affect the employer's status.
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§ 717.22(b)(2)(ii) 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:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(ii) Fee schedule including any lease agreement.
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Observations
Based on one of seven resident records reviewed, the facility failed to include documentation of a fee schedule including any lease agreement in the resident record.
Resident #2 was admitted on April 21, 2026, and was still active at the time of the inspection. There was no fee agreement provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
POC
717.22(b)(2)(ii) Beginning of Residency. (b) the licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival: (2) resident orientation to the drug and alcohol recovery house which must include: (ii) fee schedule including any lease agreement.
PROCEDURE
a. Residents will be informed of their rights and responsibilities upon intake and admission into the program. A resident handbook will be provided to each resident entailing the financial/fee schedule.
b. The financial/fee schedule will be reviewed with resident, accompanied by staff on duty to ensure understanding.
c. After ensuring the financial/fee schedule is understood, a confirmation page will be signed and added to resident charts for completion.
I have reviewed a copy of the financial/fee schedule and I agree with the financial/fee schedule. I have _____ accepted or _____ refused a copy of the financial/fee schedule.
RESIDENTS SIGNATURE ___________________________________ DATE _____________
STAFF SIGNATURE _______________________________________ DATE ______________
The Case Manager will be required to ensure that each new resident intake documentation is signed within 24 hours of arrival.
This corrective action plan is in effect currently. With the expected completion date by Monday, June 15, 2026.
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§ 717.22(b)(4) 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:
(4) Consent to residency.
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Observations
Based on one seven resident records reviewed, the facility failed to provide a consent to residency which must be signed by the resident within 24 hours.
Resident #2 was admitted on April 21, 2026, and was still active at the time of the inspection. There was not a consent to residency provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
POC
717.22(b)(2)(ii) Beginning of Residency. (b) the licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival: (4) consent to residency.
PROCEDURE
a. Residents will be informed of the policy and procedure upon intake and admission into the program, staff on duty will also provide the resident with a copy of the resident handbook.
b. After the resident is in agreeance of the policies and procedures, the resident must sign the consent to residency.
c. A copy of the signed consent to residency will be added to the resident chart for confirmation.
I am consenting to residency. I have _____ accepted or _____ refused a copy of the consent to residency.
RESIDENTS SIGNATURE ___________________________________ DATE _____________
STAFF SIGNATURE _______________________________________ DATE ______________
The Case Manager will be required to ensure that each new resident consent to residency form is signed within 24 hours of arrival.
This corrective action plan is in effect currently. With the expected completion date by Monday, June 15, 2026.
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§ 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 three of three discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.
Resident # was admitted on January 23, 2026, and was discharged February 9, 2026. There was no documentation of an end to residency including notifying the resident of the opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect in the resident record.
Resident #6 was admitted on February 6, 2026, and was discharged March 28, 2026. There was no documentation of an end to residency including notifying the resident of the opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect in the resident record.
Resident #7 was admitted on February 19, 2026, with an unknown discharge date. There was no documentation of an end to residency including notifying the resident of the opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
POC
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.
PROCEDURE
Before the decision is made to end residency, a verbal warning is given, then followed by a written warning (an incident report). Final resort is to end residency (discharge).
a) Staff will give a verbal warning to correct/change area(s) of concern.
b) If the concerns continue, staff will issue a written warning (an incident report) for areas of improvement and a timeframe to correct/change the concerns.
c) If concerns continue after the incident report, the last result is to discharge.
The infractions that lead to immediate discharge are:
1. Using any type of illicit mind-altering substances on the premises.
2. Any form of threats or physical assault towards self, staff, or others.
3. Suicide attempt or verbal intent will be referred to a HLOC
This corrective action plan will go in effect on Monday, June 1, 2026.
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§ 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 two of three applicable discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected.
Resident # 5 was admitted on January 23, 2026, and was discharged February 9, 2026. There was no notification to the emergency contact provided in the resident record.
Resident #6 was admitted on February 6, 2026, and was discharged March 28, 2026. There was no notification to the emergency contact provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
POC
717.27 Notification to family contact or emergency contact. (a) the licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the residents hospitalization or death, for notifying the residents emergency contact with the residents 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 residents 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.
POLICY:
Upon completing admissions intake, residents are asked to provide an emergency contact for any emergencies, AWOL, and/or discharge. The resident has the right to refuse an emergency contact. If the resident refuses to list an emergency contact, it must be written on the provided emergency contact form and signed by the resident and by a witnessing staff member on duty. The resident has the right to change or remove the emergency contact at any given time.
(An updated emergency contact form must be completed and added to the file for update.)
PROCEDURE IF A CASE OF EMERGENCY, AWOL, and/or DISCHARGE
1. Once notification is received of an emergency or a resident's failure to return to the site, a written incident report must be completed by the staff on duty.
2. All consented parties must be notified, including the emergency contact (unless clients have refused), by the staff on duty immediately or within 12 hours. Any attempts or contact made with the resident's emergency contacts should be documented in the written incident report, including the dates and times.
3. This documentation should be stored in the resident's file and sent out to all necessary parties.
This corrective action plan will go in effect on Monday, June 1, 2026.
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§ 717.29(d)(1)(v)(B) LICENSURE Physical plant standards - Sleep accomodation
§ 717.29. Physical plant standards.
(d) Sleeping accommodations.
(1) Each drug and alcohol recovery house bedroom must have the following:
(v) At least 50 square feet of floor space per resident measured wall to wall in each shared bedroom with bunk beds. Bunk beds must:
(B) Be equipped with a securely attached ladder capable of supporting a resident.
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Observations
Based on a physical plant inspection, the facility failed to provide a bunk bed with securely attached railing on each open side of the bunk. Bunkbeds did not have railings.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
POC
717.29 Physical plant standards. (d) each drug and alcohol recovery house bedroom must have the following: (v) at least 50 square feet of floor space per resident measured wall to wall in each shared bedroom with bunk beds. Bunk beds must: (c) be equipped with securely attached railings on each open side and open end of the bunk.
Staff will conduct a physical plants inspection in all bedrooms to check and ensure all bunks have rails on each open side and open end of the bunk.
All bunks that are without the rails, will be now added by maintenance.
Moving forward, if the facility adds any more bunk beds to the site, maintenance will ensure that all bunks have railings on each open side and the open end of the bunk.
This corrective action plan is in effect currently. With the expected completion date by Monday, June 15, 2026.
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