INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sojourner House, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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.
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Observations
Based on a review of the facility fire drill log for the months of April 2025 through February 2026, the facility failed to provide documentation of a fire drill being conducted the month of November 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The facility acknowledges that the November 2025 fire drill was not documented.
Effective immediately, the facility has implemented a monthly fire drill tracking system to ensure compliance. A designated Fire Safety Coordinator (Direct Care Supervisor or designee) is responsible for scheduling and conducting all fire drills. A monthly compliance calendar has been established to ensure drills are conducted and documented every month without exception.
Additionally, a secondary administrative review process has been implemented. The Program Director (or designee) will review the fire drill log monthly to ensure completion and documentation.
All supervisory and direct care staff have been re-educated on fire drill requirements, including the requirement for monthly unannounced drills.
Monitoring:
Fire drill logs will be reviewed monthly by leadership to ensure ongoing compliance.
Completion Date: 03/31/2026
Responsible Party: Director of Programs / Direct Care Supervisor
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill log for the months of April 2025 through February 2026, the facility failed to maintain a complete written fire drill record.
The April 6, 2025 fire drill record did not include the amount of time it took for evacuation and whether the fire alarm or smoke detector was operative.
The April 12, 2025 fire drill record did not include the exit route used and whether the fire alarm or smoke detector was operative.
The April 16, 2025 fire drill record did not include whether the fire alarm or smoke detector was operative.
The May 4, 2025 fire drill record did not include whether the fire alarm or smoke detector was operative.
The July 31, 2025 fire drill record did not include whether the fire alarm or smoke detector was operative.
The October 6, 2025 fire drill record did not include the amount of time it took for evacuation, the exit route used, and whether the fire alarm or smoke detector was operative.
The December 7, 2025 fire drill record did not include whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
P147 ? Incomplete Fire Drill Documentation
Regulation: 705.10 (d)(4)
Plan of Correction:
The facility acknowledges that fire drill documentation was incomplete on multiple occasions.
Effective immediately, a revised Fire Drill Log Form has been implemented to include all required elements:
- Date and time
- Evacuation time
- Exit route used
- Number of persons present
- Problems encountered
- Confirmation that fire alarm/smoke detector was operative
All staff responsible for conducting fire drills have been retrained on proper documentation requirements.
Additionally, the Direct Care Supervisor (or designee) will review each fire drill log within 24 hours of completion to ensure all required fields are completed. Any incomplete documentation will be corrected immediately.
Monitoring:
Monthly audits of fire drill documentation will be conducted by the Program Director.
Completion Date: 03/31/2026
Responsible Party: Direct Care Supervisor / Program Director
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the facility's fire drill log for the months of April 2025 through February 2026, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. An overnight fire drill was conducted in December 2024. The next overnight fire drill was due by June 2025; however, this was not conducted until February 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
P149 ? Failure to Conduct Overnight Fire Drills Every 6 Months
Regulation: 705.10 (d)(5)
Plan of Correction:
The facility acknowledges that an overnight fire drill was not conducted within the required 6-month timeframe.
Effective immediately, the facility has implemented a biannual overnight fire drill schedule, tracked on a compliance calendar. Overnight drills will be conducted at least every 6 months during sleeping hours.
The Fire Safety Coordinator will be responsible for scheduling and completing overnight drills, and leadership will maintain a tracking log with due dates to ensure timely completion.
Staff have been re-educated on the requirement for overnight fire drills.
Monitoring:
The Program Director will review fire drill schedules quarterly to ensure compliance with overnight drill requirements.
Completion Date: 03/31/2026
Responsible Party: Director of Programs / Direct Care Supervisor
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of April 2025 through February 2026, the facility failed to utilize alternating exits during all reviewed monthly fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
P151 ? Failure to Utilize Alternate Exit Routes
Regulation: 705.10 (d)(6)
Plan of Correction:
The facility acknowledges that alternate exit routes were not consistently utilized during fire drills.
Effective immediately, the facility has implemented a rotating exit route schedule to ensure that all available exits are used during fire drills.
A Fire Drill Planning Log will identify the designated exit route prior to each drill to ensure variation and compliance.
Staff have been retrained on the importance of utilizing alternate exit routes during drills to ensure preparedness in different emergency scenarios.
Monitoring:
Exit routes will be reviewed during monthly fire drill audits to ensure rotation is occurring.
Completion Date: 03/31/2026
Responsible Party: Direct Care Supervisor
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P153 ? Fire Drills Not Conducted Across Varying Times/Shifts (Alarm Not Activated)
Regulation: 705.10 (d)(7)
Plan of Correction:
The facility acknowledges that fire drills were not consistently conducted across varying times/shifts and that the fire alarm/smoke detector was not activated during each drill.
Effective immediately, the facility has implemented:
- A rotating fire drill schedule to ensure drills occur on different days, times (including overnight), and staffing shifts
- A requirement that the fire alarm or smoke detector be activated during every fire drill, in accordance with the regulation
Staff have been retrained on full fire drill procedures, including alarm activation and varying drill conditions.
A Fire Drill Checklist has been implemented to ensure all regulatory components are completed during each drill.
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705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill log for the months of April 2025 through February 2026, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
P153 ? Fire Drills Not Conducted Across Varying Times/Shifts (Alarm Not Activated)
Regulation: 705.10 (d)(7)
Plan of Correction:
The facility acknowledges that fire drills were not consistently conducted across varying times/shifts and that the fire alarm/smoke detector was not activated during each drill.
Effective immediately, the facility has implemented:
- A rotating fire drill schedule to ensure drills occur on different days, times (including overnight), and staffing shifts
- A requirement that the fire alarm or smoke detector be activated during every fire drill, in accordance with the regulation
Staff have been retrained on full fire drill procedures, including alarm activation and varying drill conditions.
A Fire Drill Checklist has been implemented to ensure all regulatory components are completed during each drill.
Monitoring:
All fire drills will be reviewed by the Direct Care Supervisor within 24 hours, and monthly oversight will be conducted by the Program Director.
Completion Date:03/31/2026
Responsible Party: Direct Care Supervisor / Program Director
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709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in one of one applicable record.
The facility's policy and procedure states if a client is discharging against facility advice, the Sojourner House staff on duty must call the client's emergency contact within twenty-four hours and the designated on-call employee immediately.
Client #6 was admitted on November 5, 2025 and was discharged on November 7, 2025. There is a consent for the emergency contact in client #6's record.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 26, 2025 annual licensing inspection.
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Plan of Correction
POC 709.51(a)(4) Licensure involuntary discharge/termination criteria:
1737
All staff will receive a copy of the Sojourner House Handbook that explains the involuntary discharge/termination criteria. The handbook will be reviewed at the treatment team meeting on 4/15/26 to ensure comprehension of information and answer any questions.
All staff received a copy of the on-call schedule and protocol on 3/30/26. This will be reviewed at the treatment team meeting on 4/15/26, and staff will be shown where to document phone calls to the emergency contact within 24 hours.
Responsible for monitoring: Clinical Administrator and Clinical Manager.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in three of five applicable records.
Client #3 was admitted on December 12, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on February 9, 2026. A treatment and rehabilitation plan update was due no later than March 11, 2026; however, this was not completed at the time of the inspection.
Client #4 was admitted on August 28, 2025 and was discharged on January 5, 2026. A treatment and rehabilitation plan update was completed on November 25, 2025. A treatment and rehabilitation plan update was due no later than December 25, 2025; however, this was not completed until December 26, 2025.
Client #7 was admitted on July 16, 2025 and was discharged on December 10, 2025. A treatment and rehabilitation plan was developed on July 21, 2025. A treatment and rehabilitation plan update was due no later than August 21, 2025; however, this was not completed until August 27, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC 709.52(b) Treatment Plan Update
1771
Clinical staff will be provided with a copy of the DDAP regulations and retrained on treatment plan timeframes/expectations by 4/15/26.
The Clinical Administrator will create a tracking form to ensure compliance with treatment plan guidelines. The Clinical Administrator will ensure that the Electronic Health Record sends a treatment plan reminder alert to clinical staff every 30days.
Responsible Party: Clinical Administrator and Clinical Manager
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in five of five applicable records. The facility policy and procedure manual indicate a case consultation to occur every thirty days.
Client #2 was admitted on January 13, 2026 and still active at the time of the inspection. A case consultation was due to occur no later than February 13, 2026; however, this was not completed at the time of the inspection.
Client #3 was admitted on December 12, 2025 and was still active at the time of the inspection. A case consultation was due to occur no later than January 12, 2026; however, this was not completed at the time of the inspection.
Client #4 was admitted on August 28, 2025 and was discharged on January 5, 2026. A case consultation was due to occur no later than September 28, 2025; however, this was not completed prior to discharge.
Client #5 was admitted on July 31, 2025 and was discharged on November 13, 2025. A case consultation was due to occur no later than August 31, 2025; however, this was not completed prior to discharge.
Client #7 was admitted on July 16, 2025 and was discharged on December 10, 2025. A case consultation was due to occur no later than August 16, 2025; however, this was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
POC 709.53 Case Consultation
1807
Per Sojourner House Policy, case consultations will be completed every 30 days for each client and documented in the EHR.
The case consultation policy will be distributed and reviewed with all clinical staff by 4/15/2026.
Responsible Party: Clinical Administrator and Clinical Manager will monitor case consults monthly during the treatment team meeting.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in four of four applicable records. The policy and procedure manual indicates follow-up contact must be made within seven days of discharge.
Client #4 was admitted on August 28, 2025 and was discharged on January 5, 2026. Follow-up contact was due to be completed no later than January 12, 2026; however, this was not completed at the time of the inspection.
Client #5 was admitted on July 31, 2025 and was discharged on November 13, 2025. Follow-up contact was due to be completed no later than November 20, 2025; however, this was not completed at the time of the inspection.
Client #6 was admitted on November 5, 2025 and was discharged on November 7, 2025. Follow-up contact was due to be completed no later than November 14, 2025; however, this was not completed at the time of the inspection.
Client #7 was admitted on July 16, 2025 and was discharged on December 10, 2025. Follow-up contact was due to be completed no later than December 17, 2025; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
POC 709.53(a)(11) Follow -up information
1813
Clinical staff will be provided with a copy of the DDAP regulations and retrained on follow-up procedures, documentation processes, and timeframes by 4/15/26.
Clinical staff will receive 7-day follow-up reminders/alerts from the Electronic Health Record, and the Clinical Administrator will review recent discharges in the weekly treatment team meeting to ensure compliance.
Responsible Party: Clinical Administrator and Clinical Manager
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