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 7KXF6701 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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§ 717.19(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
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.
Also as of 2/18/2026 We are now using consent to residency form that includes emergency contact information. It is the last page of our resident handbook
1. It has been reviewed with house lead and house manager to complete with house residents upon beginning of residency.
2. The house lead is responsible for making sure form is completed and acknowledged.
3.The form is expected to be done with
both resident and house lead and put into resident binder.
4. The house manager will be completing an inspection on all new binders weekly
that includes the emergency contact section is completed. House manager will also check in with house lead when someone has left the facility.
5.The house lead is responsible to notify emergency contact and update house manager and make sure it is noted on the emergency notification form.
Date of correction completed 2/18/2026
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§ 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
As of 2/18/2026 We are now using the referral form that includes. It is now part of our resident handbook.
1. It has been reviewed with house lead and house manager to complete with house residents upon beginning and ending of residency.
2. The house lead is responsible for making sure form is completed with resident and stored induvial binders.
3. The house manager will be completing an inspection on all binders weekly
that includes form.
Date of correction completed 2/18/2026
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§ 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
Plan of Correction:of citation 0220 is as follows
The plan of correction Step by Step Recovery has now implemented an excel spreadsheet for all new residents for our resident roaster and also our now using One Step Software . The completion of all resident is now in place .
The responsibility of this task will be the GM
Completion date 2/10/26 |
? 717.22(b)(3)(i)-(ii) 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:
(i) Name.
(ii) Birth date.
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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
As of 2/18/26 we have added the missing information to the basic personal data form (intake) form
Also as of 2/18/2026 We are now using the referral form that includes. It is now part of our resident handbook.
1. It has been reviewed with house lead and house manager to complete with house residents upon beginning and ending of residency.
2. The house lead is responsible for making sure form is completed with resident and stored induvial binders.
3. The house manager will be completing an inspection on all binders weekly
that includes form.
Date of correction completed 2/18/2026
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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 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
717.23 LICENSURE
Notification of decision to end residency:
§ 717.23. Notification of decision to end residency. (a) The Step by Step 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.
We will also give resident three referrals to call or go to so they are not homeless .
We will make sure the house lead has. The end of residency form signed and what type of discharge was it Administer discharge, Use off illicit drugs or alcohol form signed by house lead and departing resident . Also the GM will make monthly visit to ensure the paperwork is being completed down correctly.
The person responsible -House Lead
Date of completion 2/12/26 |
§ 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
Step by Step plan of correction is implementation of the new form we have now made part of the intake process.
(a) The notification of the residents emergency contacts, typically family members or designated individuals, has been implemented by SBSRH.
(b) This plan outlines the procedures and circumstances, including the resident's hospitalization or demise, for notifying the resident's emergency contact with their consent. The resident retains the authority to withdraw consent for the notification process.
(c) Step by Step Recovery Houses is obligated to make at least one attempt to contact the resident's emergency contact immediately and within 12 hours of the resident's decision to terminate residency or failure to return to the drug and alcohol recovery .
The responsibility of keeping these records up to date is the House Lead. The GM will make monthly visit to ensure said records are kept up to date
Date of completion 2/14/2026 and moving forward. |
§ 717.29(b)(1) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(1) Keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
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Observations
Based on review of the physical plant inspection the recovery house failed to
keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of 2/23/2026 The plan of correction is as follows:The plan of correction is SBSRH has implemented a new chore chart system.If the resident does not follow there daily chore they will be written up for not doing there daily chore we also have implemented that every Sunday will be GI day which is mandatory for all house members to comply
The person responsible is the Assistant House Lead
to sign off every day on our chore chart form
This includes interior and exterior of all our facilities
These findings were discussed with the recovery house staff during our weekly house meeting.
The GM will do random stops to each house to make sure there being complete. Also, every house member we have a chat for each house has to take a picture before and after other chore for the day we implemented and was completed by 2/23/25 |
§ 717.29(g)(2) LICENSURE Physical plant standards - Heating-Cooling
§ 717.29. Physical plant standards.
(g) Heating and cooling. The licensee:
(2) May not use or permit portable space heaters.
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Observations
Based on review of the physical plant inspection the recovery house is using space heaters which is not permitted.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction
Step by Step acknowledges the citation# 0396.
The plan of correction is as follows the house lead will follows the addition to our weekly check list .That when we do our weekly room checks ,space heaters was added to the house lead checklist and whom ever violating this rule will be written up and sanction will be implemented the GM will check the house leads check list monthly.
Completion date 2/19/26 |
§ 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
The plan of correction Step by Step
We will visit a certified inspection station, to have every single fire extinguisher from each house inspected by a certified fire extinguisher inspector.
We will conduct this inspection annually.
Now, it's evident that this must be done annually. Therefore, the fire extinguishers will be taken to the Upper Darby inspection station, which is a certified inspection station.
The person responsible is the House Lead we will do monthly checks and implemented a form which the General Manager will sign off on when the health and safety walk throughs are done on monthly basis
Completion date 2/21/26
Also the general manager and owner will be responsible for maintaining functional, inspected fire extinguishers annually. |