INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection YY6U6701 Step by Step 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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§ 717.12 LICENSURE Refusal or revocation of license
§ 717.12. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the
Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the drug and alcohol recovery house.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or
attempting to obtain a license.
(6) Lending, borrowing or using the license of another drug and alcohol recovery house.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing residents at the drug and alcohol recovery house.
(9) Continued noncompliance in disregard of this part.
(10) Operating a drug and alcohol recovery house that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the applicant or licensee by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the drug and alcohol recovery house to correct deficiencies.
(c) If the drug and alcohol recovery house does not correct the deficiencies within the specified time, the Department will officially notify the applicant or licensee that it shall show cause why its license should not be denied or revoked under 1 Pa. Code § 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. The applicant or licensee shall file a written request within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code § 35.14.
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Observations
Based on an approved plan of correction that was submitted for the 2024 and the onsite license renewal for 2025, the recovery house failed to comply with a plan of correction approved by the Department, unless the Department approves and extension or modification of the plan of correction.
Based on the previous and current technical assistance provided, prior citations the recovery house failed to comply with a plan of correction approved by the Department, unless the Department approves and extension or modification of the plan of correction and failed to comply with a directive issued by the Department.
1. Failure to complete and return required documentation of data collection form
2. Failure to complete required documentation of attestation form
3. Resident rights missing in records
4. Incomplete Data Collection
5. No contact made to family member or emergency contact
6. No resident roster being maintained
7. Faulty fire extinguisher inspection tags
8. Missing resident records
9. Does not maintain referral documentation or provide referrals.
10. No notifications of decision to end residency
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Plan of Correction
The plan of correction on citation 0153 - will be completed as follows The owner will oversee that the above-mentioned deficiencies are corrected and implemented by 2/26/26. The owner is responsible to ensure that these deficiencies will not reoccur |
§ 717.19(b) LICENSURE Resident Rights
§ 717.19. Resident rights.
(b) The licensee shall obtain written acknowledgement by residents that they have received notice of their rights.
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Observations
Based on review of the resident records, the recovery house failed to provide resident rights.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
0201 ? AS of 2/18/2026 we are now using DDAP resident rights which has been added to the orientation handbook and on the consent to residency where resident will sign and date within 24 hours of arrival.
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§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
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Observations
Based on requests to review records, the recovery house failed to provide discharge records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
0202 ? All records will be kept in a locked safe or maintained on One Step. If the records are paper copies the only person who will have access is the general manager and owner. House leads may have access but for specific reasons. This will prohibit the ability of records to go missing. The owner and general manager will ensure that this does not recur by completing a weekly record check. This is implemented on 2/23/26. |
§ 717.20(a)(3) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(3) Referrals to and from the drug and alcohol recovery house, if
applicable.
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Observations
Based on review of the resident records and interview with the house manager, the recovery house failed to provide referrals to and from the recovery house.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
0204 - On 2/23/26 the recovery house has put a resource binder together for resident access for all services in the community. The recovery house will also document if a resident has been referred out to services. The owner is responsible for ensuring that the documentation has been added to the records by completing record checks. |
§ 717.21(a) LICENSURE Resident Roster
§ 717.21. Resident roster.
(a) The licensee shall maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
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Observations
Based on review of the resident records, the recovery house failed to have a resident roster.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
0220 ? A resident roster of the admission date and end date has been implemented on 2/10/26. The resident roster will be utilized in One Step. We are also maintaining a copy of the resident roster on an excel spreadsheet. It is the responsibility of the owner to ensure that all incoming and discharged residents have been properly documented |
§ 717.22(b)(3)(vii) 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:
(3) Basic personal data including:
(vii) Emergency contact.
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Observations
Based on review of resident records the recovery house failed to collect full basic personal data.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction ? 717.20(a)(3) Resident Records: Referrals
Deficiency:The recovery house did not maintain documentation of referrals to and from the recovery house in resident records, as required by 717.20(a)(3).
Corrective Action Completed:
The house manager reviewed all current resident files and added referral documentation where applicable. For residents who entered without a formal referral, a notation has been added to the record indicating "No referral provided at admission."
Step by Step Prevention Measures:
A standardized Referral Documentation Form has been created and added to the admission and discharge packet.
Staff will complete this form at intake and discharge for every resident, regardless of referral source.
The form will be filed in the resident's record immediately upon completion.
Staff Training:
All staff responsible for admissions and recordkeeping will receive training on the referral documentation requirement and the and the updated process by 2/15/2026 Training will be documented and kept on file.
Ongoing Monitoring:
The house manager will conduct a monthly audit of 10% of resident files to ensure referral documentation is consistently completed. Any missing documentation will
be addressed through retraining.
Completion Date:All corrective actions will be fully implemented by 2/15/2026
Responsible staff is director and General Manager. |
§ 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 review of the 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.
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Plan of Correction
The plan of correction for citation
0260 ? Written notification of discharge letter has been created and implemented on 2/9/25. If a resident refuses to sign it will be noted in the system or on the notification form. To ensure that this does not recur, the owner and general manager will check records weekly to ensure that all documentation of discharge has been obtained. |
§ 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 a review of resident records, the recovery house failed to make at least one attempt to notify the resident ' s emergency contact in accordance with subsection 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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
0310 - As of 2/14/26 the recovery house has begun documenting when an emergency contact is notified with 12 hours of any administrative discharges, no return to the house, hospitalization and death. The emergency contact information is gathered at the time of admission. When emergency contact information must be notified it will be documented in the record stating date and time, if message was left or spoken to someone. The owner is responsible for ensuring the call to the emergency contact is completed within 12 hours by reaching out to house manager or house lead when notified of discharge and ensuring that the contract is made. The owner will ensure this does not recur by maintaining communication with house manager and house leads 3 times a week. |
§ 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 review of the fire extinguishers located throughout that property, the recovery house failed to have fire extinguishers inspected and approved annually by the local fire department or fire extinguisher company.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
0437 ? Add that the general manager and owner will be responsible for maintaining functional, inspected fire extinguishers annually. |