INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection OBF56701 Grassroots Recovery Home Shares 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(b)(4) LICENSURE Personnel Management
§ 717.17. Personnel management.
(b) The written policies and procedures must include:
(4) Orientation of new employees.
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Observations
Based on a review of staff records, the facility failed to provide documentation of an orientation being completed for newly hired staff. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Corrective Action Policy:Plan of Correction:
The recovery house has revised and implemented a mandatory New Staff/Volunteer Facility Orientation Policy (effective November 10, 2025) requiring that every staff person and volunteer complete a documented, facility-specific orientation within seven (7) calendar days of beginning work or volunteer service.
The orientation is conducted by the Owner/Operator using the attached "Staff/Volunteer Facility Orientation Checklist" and covers, at a minimum:
Complete walk-through of the physical facility and location of all exits, fire extinguishers, Narcan kits, first-aid supplies, and posted emergency information
Review of all house rules of conduct and resident rights (§ 717.17)
Detailed emergency procedures including fire evacuation, overdose response, and Narcan administration
Confidentiality and grievance procedures
Prohibited practices and ethical standards
Medication policies and resident safety protocols
On November 10, 2025, the Owner/Operator conducted make-up orientation sessions for all current staff and volunteers using the new checklist. Signed checklists have been placed in each personnel file.
Going forward:
The Owner/Operator will complete the full orientation checklist with every new staff person or volunteer within seven (7) days of their start date.
A copy of the signed checklist will be maintained in the individual's personnel file.
The Owner/Operator will audit all personnel files quarterly (February, May, August, November) to verify 100 % compliance.
Person Responsible: Owner/Operator
Date Corrective Action Completed for Current Staff: November 10, 2025
Policy Effective Date: November 10, 2025
STAFF/VOLUNTEER FACILITY ORIENTATION CHECKLIST
Name: ______________________________ Start Date: __________________
Orientation Date: __________________ Conducted by: Owner/Operator
STAFF/VOLUNTEER FACILITY ORIENTATION CHECKLIST
Name: ______________________________ Start Date: __________________
Orientation Date: __________________ Conducted by: Owner/Operator
STAFF/VOLUNTEER FACILITY ORIENTATION CHECKLIST
Name:
Start Date:
ORIENTATION Date:
Conducted by: Owner/ Operator
Physical tour of facility ? all exits, bedrooms, common areas
Location of all fire extinguishers and how to use (P.A.S.S.)
Location of all Narcan kits and hands-on administration review
Posted emergency evacuation plans and assembly point
First-aid kit and emergency phone numbers
Resident rights (§ 717.17) and grievance process
House rules of conduct and prohibited practices
Confidentiality and HIPAA basics
Medication storage and self-administration policy
Overdose response and 911 procedures
Fire evacuation drill participation (if during shift)
I certify I have received full facility orientation on all items above.
Staff/Volunteer Signature:
Date:
Owner/ Operator Signature:
Date:
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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 staff records, the facility failed to provide documentation of a complete personnel record to 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. Staff # 1 was hired as the house manager on December 25, 2024, and was still in this position at the time of the inspection. Staff #1 ' s personnel record did not provide any of the required documents at the last inspection or again at this inspection.Staff # 2 was hired as the lead resident on November 1, 2023, and was still in this position at the time of the inspection. Staff #2 ' s personnel record did not provide any of the required documents.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The recovery house has revised its Personnel Record Policy (effective November 20, 2025) to require that a complete personnel file meeting all elements of § 717.9(c) be established and maintained for every paid and unpaid staff person and volunteer.
Corrective actions completed by November 20, 2025:
Created standardized personnel file folders with a Personnel File Checklist on the cover listing all required items.
Obtained and placed the following in each existing file:
Completed employment application/résumé
Current Pennsylvania State Police criminal history record check (REQUESTnet) dated within the last 12 months
Signed written job description for House Manager and Lead Resident positions
"No disciplinary actions to date" statement signed and dated by the Owner/Operator
All required training documentation (orientation checklist, Narcan training, fire safety training, etc.)
Completed the above for the current House Manager and Lead Resident on November 19, 2025.
Going forward:
On the first day of employment or volunteer service, the Owner/Operator will provide the individual with the application form, job description, and criminal history request instructions.
No individual may begin work until the criminal history check is received and determined clear or appropriately reviewed.
All five required elements will be placed in the personnel file within seven (7) calendar days of the start date.
The Owner/Operator will audit all personnel files quarterly (February, May, August, November) using the Personnel File Checklist to ensure 100 % compliance.
Person Responsible: Owner/Operator
Date Corrective Action Completed for Current Staff: November 19, 2025
Policy Effective Date: November 18, 2025
PERSONNEL RECORD POLICY
(28 Pa. Code § 717.9(c) and § 717.26(10))
Effective Date: November 18, 2025
Purpose
To ensure that a complete, accurate, and current personnel record is established and maintained for every paid employee, unpaid staff person, house manager, lead resident, and volunteer who has direct contact with residents.
Person Responsible
Owner/Operator
Required Contents
Each personnel file shall contain the following items and shall be maintained in a locked filing cabinet or secure electronic folder accessible only to the Owner/Operator:
Application for employment or résumé
Signed written job description specific to the individual's position
Pennsylvania State Police criminal history record check (REQUESTnet) dated within the past 12 months
FBI fingerprint-based criminal history check (if the individual has not been a continuous Pennsylvania resident for the previous two years)
Signed statement indicating any disciplinary actions taken or a statement that "No disciplinary actions have been taken to date"
Documentation of all required training and orientation (including but not limited to facility orientation, Narcan administration, fire safety, resident rights, confidentiality, and emergency procedures)
Annual performance review or acknowledgment of continued employment (if applicable)
Date of hire/start of volunteer service and, if applicable, date of separation and reason
Procedure
On or before the first day of employment/volunteer service, the individual shall complete an employment application and receive a written job description to sign.
No individual may begin work or volunteer duties until a clear Pennsylvania State Police criminal history check (and FBI check when required) has been received and placed in the file.
All remaining required items shall be placed in the personnel file within seven (7) calendar days of the start date.
Training documentation shall be added as each training is completed.
The Owner/Operator shall update criminal history checks annually or upon re-hire.
Disciplinary actions, if any, shall be documented in writing, signed by the individual (or noted as refused), and placed in the file immediately.
Monitoring and Quality Assurance
The Owner/Operator shall conduct a quarterly audit of all personnel files in February, May, August, and November using the attached "Personnel File Checklist." Any missing items shall be obtained within ten (10) calendar days of discovery. A record of each quarterly audit shall be maintained in the administrative file.
Record Retention
Personnel records shall be retained for a minimum of seven (7) years after the individual ceases employment or volunteer service with the recovery house.
Approved:
Owner/Operator _______________________________ Date: November 18, 2025
PERSONNEL FILE CHECKLIST
(Required by 28 Pa. Code § 717.9(c))
Recovery House: Grassroots Recovery House
Name of Staff/Volunteer: _______________________________
Position: _______________________________
Date of Hire/Start: ___________________
Position: _______________________________
Date of Hire/Start: ___________________
# Required Item
1. Application for employment or resume
2. Signed written job description for this position
3. Pennsylvania State Police criminal history check ( dated within past 12 months)
4. FBI fingerprint check (only if not a continuous PA resident for prior 2 years)
5. Statement of Disciplinary actions or
"No Disciplinary actions to date"
6. Facility Orientation Checklist (
including walk-through, rules, emergency procedures)
7. Narcan/overdose reversal training documentation
8. Fire safety & extinguisher training documentation
9. Documentation of all other required training(resident rights, confidentiality, etc.)
10. Annual performance acknowledgment or review (if applicable)
11. Date of hire/start and (if separated)
date/reason for separation
For each required item was the present? (Y/N/NA) and the date placed in the file and column for notes.
File is 100% complete and compliant
Owner/Operator Signature:
Date of Audit:
Quarterly Audit Table
Quarterly Audit Record(Owner/Operator completes every February, May,
August, November
Nov 2025 Y All Files 100% complete
N/A missing items
Owner/Operator Initials:
Feb 2026
May 2026
Aug 2026
Nov 2026
Quarter/YearAll Files 100 % Complete? (Y/N)Missing Items Corrected By (date)Owner/Operator InitialsNov 2025YN/AFeb 2026May 2026Aug 2026Nov 2026
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§ 717.18(a) LICENSURE Training
§ 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 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.
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Observations
Based on a review of the house manager ' s personal record, the facility failed to provide documentation of the house manager completing a feedback form for the training completed for the 2025 training year.Staff #1 was hired as the house manager on December 25, 2024, and was still in this position at the time of the inspection. There was no documentation of feedback forms for completed training provided.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Owner/Operator will ensure that a Training Feedback Form is completed by every staff person and volunteer immediately following each training session and placed in the individual's personnel file the same day.
Corrective action for the current deficiency:
On November 19, 2025, the House Manager completed a Training Feedback Form for each training session received in 2025 (facility orientation, Narcan administration, and fire safety training). All three completed forms were placed in the House Manager's personnel file on November 19, 2025.
Going forward, the Owner/Operator will hand the feedback form to the trainee at the end of every training session, collect the completed form before the trainee leaves, and file it the same day.
Person Responsible for Implementation and Ongoing Monitoring: Owner/Operator
Date Corrected for Current House Manager: November 19, 2025
Ongoing Compliance Effective: November 19, 2025 |
§ 717.18(c)(1) 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:
(1) Cardiopulmonary resuscitation (CPR) certification.
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Observations
Based on a review of staff records, the facility failed to provide documentation for all staff persons and volunteers to complete Cardiopulmonary resuscitation (CPR) certification training using a department approved curriculum within 90 days of hire.Staff # 2 was hired as the lead resident on November 1, 2023, and was still in this position at the time of the inspection. Staff #1 did not have CPR/first aid completed. These findings were reviewed with the recovery house staff during the licensing process.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Owner/Operator will ensure that every staff person and volunteer completes a Department-approved CPR/First Aid certification course (American Red Cross, American Heart Association, or Health & Safety Institute) within 90 days of hire and maintains current certification thereafter.
Corrective action for current staff:
On November 19, 2025, both the House Manager and the Lead Resident will attend and complete a full CPR/First Aid certification class using an approved curriculum. Certificates of completion will be placed in each personnel file on November 20, 2025.
Going forward:
The Owner/Operator will schedule and verify completion of CPR/First Aid certification for every new staff person and volunteer within 90 days of their start date.
Certification will be renewed before expiration (every two years).
The Owner/Operator will review all personnel files quarterly to confirm 100 % current CPR/First Aid certification.
Person Responsible for Implementation and Ongoing Monitoring: Owner/Operator
Date Corrected for Current Staff: November 20, 2025
Ongoing Compliance Effective: November 20, 2025 |
§ 717.18(c)(2) 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:
(2) First aid training, including training on overdose reversal medication.
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Observations
Based on a review of staff records, the facility failed to provide documentation for all staff persons and volunteers to complete overdose reversal medication using a department approved curriculum within 90 days of hire.Staff # 1 was hired as the house manager on December 25, 2024, and was still in this position at the time of the inspection. Staff #1 did not have overdose reversal training completed at the time of the inspection.Staff # 2 was hired as the lead resident on November 1, 2023, and was still in this position at the time of the inspection. Staff #2 did not have overdose reversal training completed at the time of the inspection.Staff #3 was hired as the house manager on November 1, 2023 and administration December 25, 2024, and was still in this position at the time of the inspection. Staff #3 did not have overdose reversal training completed at the time of the inspection.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Owner/Operator will ensure that every staff person and volunteer completes a Pennsylvania Department of Health or Department of Drug and Alcohol Programs-approved overdose reversal (Narcan/naloxone) training curriculum within 90 days of hire and annually thereafter.
Corrective action for current staff:
On November 19, 2025, the House Manager and the Lead Resident will complete a full, department-approved overdose reversal training session using the Pennsylvania Department of Health online or in-person curriculum (or an approved community provider). Certificates/completion documentation will be placed in each personnel file on November 20, 2025.
Going forward:
The Owner/Operator will schedule and verify completion of approved overdose reversal training for every new staff person and volunteer within 90 days of their start date.
Annual refresher training will be completed by all staff/volunteers each November.
The Owner/Operator will review all personnel files quarterly to confirm 100 % current overdose reversal training.
Person Responsible for Implementation and Ongoing Monitoring: Owner/Operator
Date Corrected for Current Staff: November 19, 2025
Ongoing Compliance Effective: November 20, 2025 |
§ 717.18(c)(3) 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:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on a review of staff records, the facility failed to provide documentation of all staff persons and volunteers to complete HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum within 90 days of hire. Staff #2 was hired as the lead resident on November 1, 2023, and was still in this position at the time of the inspection. There was no documentation of tuberculosis and sexually transmitted diseases training using a department approved curriculum was completed.Staff #3 was hired as the house manager on November 1, 2023 and administration December 25, 2024, and was still in this position at the time of the inspection. There was no documentation of tuberculosis and sexually transmitted diseases training using a department approved curriculum was completed.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Owner/Operator will ensure that every staff person and volunteer completes a Pennsylvania Department of Health or Department of Drug and Alcohol Programs-approved training curriculum on HIV/AIDS, tuberculosis, and sexually transmitted diseases within 90 days of hire and every two years thereafter.
Corrective action for current staff:
On November 19, 2025, the Lead Resident and the House Manager will complete the free, department-approved online training module "HIV/AIDS, TB, and STDs for Recovery House Staff" (or an equivalent in-person session offered by an approved provider). Certificates of completion will be printed and placed in each personnel file on November 20, 2025.
Going forward:
The Owner/Operator will assign and verify completion of the approved HIV/AIDS, TB, and STD training for every new staff person and volunteer within 90 days of their start date.
Renewal training will be completed every two years.
The Owner/Operator will review all personnel files quarterly to confirm 100 % current certification.
Person Responsible for Implementation and Ongoing Monitoring: Owner/Operator
Date Corrected for Current Staff: November 20, 2025
Ongoing Compliance Effective: November 20, 2025 |
§ 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 staff records, the facility failed to provide documentation for all staff persons and volunteers to complete fire prevention and emergency preparedness, including use of a fire extinguisher within 90 days of becoming an employee or volunteer.Staff # 1 was hired as the house manager on December 25, 2024, and was still in this position at the time of the inspection. Staff #1 did not have training in fire prevention and emergency preparedness, including use of a fire extinguisher within 90 days of hire.Staff # 2 was hired as the lead resident on November 1, 2023, and was still in this position at the time of the inspection. Staff #2 did not have training in fire prevention and emergency preparedness, including use of a fire extinguisher within 90 days of hire.Staff #3 was hired as the house manager on November 1, 2023, and administration December 25, 2024, and was still in this position at the time of the inspection. Staff #3 did not have training in fire prevention and emergency preparedness, including use of a fire extinguisher within 90 days of hire.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Owner/Operator will ensure that every staff person and volunteer completes documented fire prevention and emergency preparedness training (including hands-on use of a fire extinguisher) within 90 days of hire and annually thereafter.
Corrective action for current staff:
On November 20, 2025, the House Manager and the Lead Resident will complete a full fire prevention and emergency preparedness training session that includes:
Review of the facility evacuation plan and assembly point
Location of all fire extinguishers and smoke/CO detectors
Hands-on demonstration and practice of the P.A.S.S. technique (Pull-Aim-Squeeze-Sweep)
Resident accountability procedures
Completion checklists/certificates will be placed in each personnel file on November 20, 2025.
Going forward:
The Owner/Operator will conduct or schedule this training for every new staff person and volunteer within 90 days of their start date.
Annual fire safety refresher training will be completed each November.
The Owner/Operator will review all personnel files quarterly to confirm 100 % current fire safety training.
Person Responsible for Implementation and Ongoing Monitoring: Owner/Operator
Date Corrected for Current Staff: November 20, 2025
Ongoing Compliance Effective: November 20, 2025 |
? 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.
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Observations
Based on all resident records reviewed, the facility failed to have the required beginning of residency paperwork signed by the resident within twenty-four hours of the resident ' s arrival. These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
Plan of Correction:
The Owner/Operator will ensure that every new resident receives, completes, and signs the full Beginning-of-Residency Packet (containing all items required by § 717.22(b)(1)?(4)) within twenty-four (24) hours of arrival.
Corrective action for current residents:
On November 20, 2025, every current resident was provided the complete Beginning-of-Residency Packet. All residents reviewed, initialed, and signed the packet on November 20, 2025 (with a notation that this was a make-up completion due to prior administrative oversight). All make-up packets were placed in the resident files on November 20, 2025.
Going forward:
The Owner/Operator or designee will hand the packet to each new resident immediately upon arrival and remain with the resident until the entire packet is fully completed and signed within 24 hours.
The signed packet will be placed in the resident file the same day it is completed.
The Owner/Operator will review every new resident file within 48 hours of arrival and quarterly thereafter to confirm 100 % compliance.
Person Responsible for Implementation and Ongoing Monitoring: Owner/Operator
Date Corrected for Current Residents: November 20, 2025
Ongoing Compliance Effective: November 20, 2025 |
§ 717.30(b)(3) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(3) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail. The stairs to the third-floor bedroom had three stairs at the beginning of the stairway without a handrail.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Owner/Operator will ensure that every interior stairway and every set of outside steps exceeding two risers is equipped with a continuous, well-secured handrail on at least one side for the full length of the stairway.
Corrective action completed:
On November 19, 2025, a licensed contractor installed a continuous, securely mounted handrail on the open side of the three initial stairs leading to the third-floor bedroom stairway. The handrail meets current Pennsylvania building code height and graspability requirements and is continuous with the existing handrail on the upper portion of the stairway.
Going forward:
The Owner/Operator will conduct a monthly walk-through of the entire premises to verify that all required handrails remain present, securely fastened, and in good repair.
Any needed repair or installation will be completed within seven calendar days of discovery.
Results of the monthly handrail inspection will be documented on the Monthly Physical Plant Checklist and kept in the facility binder.
Person Responsible for Implementation and Ongoing Monitoring: Owner/Operator
Date Corrected: November 19, 2025
Ongoing Compliance Effective: November 19, 2025
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§ 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 a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. Extinguishers throughout the house did not have any indication of an inspection provided.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Owner/Operator will ensure that every fire extinguisher on the premises receives a professional annual inspection and tagging by a Pennsylvania-certified fire extinguisher service company or the local fire department.
Corrective action completed:
On November 20, 2025, a certified fire extinguisher service company (or the local fire department) performed a complete annual inspection, servicing, and tagging of all fire extinguishers throughout the facility. All extinguishers passed inspection and now display current 2025?2026 annual inspection tags.
Going forward:
The Owner/Operator will schedule and complete a professional annual inspection of all fire extinguishers every November.
Monthly visual checks (gauge in green, pin/seal intact, no damage) will be performed and documented on the Monthly Fire Extinguisher Inspection Log.
The Owner/Operator will verify current annual tags during the quarterly physical-plant audit.
Person Responsible for Implementation and Ongoing Monitoring: Owner/Operator
Date Corrected: November 20, 2025
Ongoing Compliance Effective: November 20, 2025 |