INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Grassroots Recovery Homes Shares LLC 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee files, the facility failed to document individual training plans for each employee for the 2026 training year.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Corrective Action Taken/To Be Taken 1. A standardized Individual Training Plan form has been developed that meets all requirements of § 704.11(b)(1). The form is written, is appropriate to each employee's skill level and job duties, and is developed annually with documented input from both the employee and the supervisor (attached).
2. An Individual Training Plan for the 2026 training year has been (or will be) completed for every current employee. Each plan was developed jointly with the employee and their supervisor, signed by both, and placed in the employee's personnel file.
3. Going forward, an Individual Training Plan will be developed for every employee within 30 days of hire and updated/renewed annually (by January 31 of each training year or on the employee's anniversary date). |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on staff interviews, the facility failed to document unannounced fire drills at least once a month from January 2026 - July 2026.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Corrective Action Taken/To Be Taken 1. A formal Fire Drill Log has been developed and implemented to document every unannounced fire drill. The log captures date, time, unannounced status, participants, evacuation details, problems observed, corrective actions, and signatures.
2. Effective immediately, Grassroots Recovery Outpatient will conduct and document an unannounced fire drill at least once every month in accordance with § 705.28(d)(1).
3. The missing documentation period (January?July 2026) is acknowledged. Going forward, all drills will be recorded on the Fire Drill Log on the same day they occur, and the log will be maintained on site and available for inspection.
4. Staff have been (or will be) informed of the monthly unannounced drill requirement and the new documentation process.
Method of Monitoring / Ongoing Compliance Person Responsible for Monitoring: Trisha Tait, Program Director
Method and Frequency:
The Program Director will ensure an unannounced fire drill is conducted at least once each calendar month and that the Fire Drill Log is completed the same day.
The Program Director will review the Fire Drill Log at the end of every month to confirm that a drill was conducted, was unannounced, and is fully documented. Any missed month will be corrected immediately in the following month and noted. Results of the monthly review will be recorded in the facility compliance log and discussed in staff meetings. |