INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 22, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection M83U6701 Daystar Center For Spiritual Recovery 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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§ 717.23 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 two of two discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.
Resident #3 was admitted on March 9, 2026, and was discharged April 19, 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 #4 was admitted on December 8, 2025, and discharged April 6, 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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Corrective Action:
Effective 05/26/2026, the facility has implemented a formal Residency Termination Notice process. Prior to any discharge or termination of residency initiated by the facility, residents will receive written notification that includes:
1.The reason for the proposed termination of residency.
2.The effective date of the termination.
3.The resident's right to request reconsideration of the decision before the termination takes effect.
4.Documentation of the resident's receipt of the notice.
A standardized "Notice of Residency Termination and Reconsideration Rights" form has been developed and will be maintained in each resident's record.
Measures to Prevent Recurrence:
The House Manager for has been retrained on regulatory requirements related to ending residency and resident rights. A discharge checklist has been revised to include verification that the written termination notice has been completed, signed, and filed in the resident record prior to discharge.
Monitoring:
The Program Director will review all resident discharges monthly for six months to ensure compliance with notification requirements. Any deficiencies identified will be addressed immediately through staff re-education and corrective action.
Completion Date: June 3, 2026
Responsible Person: Program Director
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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 two 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 #3 was admitted on March 9, 2026, and was discharged April 19, 2026. There was no notification to the emergency contact provided in the resident record.
Resident #4 was admitted on December 8, 2025, and discharged April 6, 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
Corrective Action:
Effective 05/26/2026, the facility has implemented a policy requiring staff to notify the resident's designated emergency contact whenever a resident:
1.Voluntarily ends residency;
2.Leaves the recovery house and does not return as expected; or
3.Is discharged from the facility under circumstances requiring notification pursuant to facility policy and regulations.
Documentation of the notification, including the date, time, method of contact, person contacted, and staff member completing the notification, will be maintained in the resident record.
Measures to Prevent Recurrence:
A Resident Discharge/Departure Checklist has been developed and implemented to ensure all required notifications are completed and documented. All staff responsible for resident supervision, discharge planning, and record maintenance have been trained on the emergency contact notification requirements.
Monitoring:
The Program Director will conduct a monthly review of all resident discharges and unplanned departures for six months to verify that emergency contact notifications were completed and properly documented in the resident record. Any identified deficiencies will be addressed immediately through corrective action and staff retraining.
Completion Date: May 26, 2026
Responsible Person: Program Director
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§ 717.30(b)(1) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(1) Ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed. The emergency exit on the third floor was obstructed and not easily accessible.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Corrective Action:
On 05/06/2026, all items obstructing the third-floor emergency exit were removed. The exit was inspected to ensure it was fully accessible and capable of being used in the event of an emergency. The facility has implemented procedures requiring all stairways, hallways, emergency exits, and means of egress to remain free of obstructions at all times. Residents and staff have been instructed that personal belongings, furniture, storage items, or other materials may not be placed in any area that could impede emergency evacuation.
Measures to Prevent Recurrence:
All staff and residents have been educated on fire safety requirements and the importance of maintaining unobstructed exits and evacuation routes. House rules have been reinforced to prohibit storage of personal items in hallways, stairwells, or near emergency exits.
A weekly safety inspection checklist has been implemented to verify that all exits, hallways, and stairways remain clear and accessible. Any identified concerns will be corrected immediately.
Monitoring:
The Program Director or House Manager will conduct and document weekly inspections of all emergency exits, stairways, and hallways for a period of six months. Inspection records will be maintained on-site and reviewed to ensure ongoing compliance. Any deficiencies identified will be corrected immediately and addressed with staff and residents as necessary.
Completion Date: May 6, 2026
Responsible Person: Program Director
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