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 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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§ 717.19(a)(2) LICENSURE Resident Rights
§ 717.19. Resident rights.
(a) The licensee shall develop and implement written policies and procedures on resident rights which must include:
(2) The licensee may not discriminate against a resident on the basis of age, race, sex, religion, ethnic origin, economic status, disability, sexual orientation or gender identity or expression.
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Observations
Based on two resident records reviewed, the facility failed to include the resident rights to include the verbiage that the licensee may not discriminate against a resident on the basis of age, race, sex, religion, ethnic origin, economic status, disability, sexual orientation or gender identity or expression. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Corrective Action Taken/To Be Taken1. The written Resident Rights policy and the Resident Rights Acknowledgement form have been immediately revised to include the exact required language from § 717.19(a)(2): "The licensee may not discriminate against a resident on the basis of age, race, sex, religion, ethnic origin, economic status, disability, sexual orientation or gender identity or expression."
2. The complete Resident Rights document now lists all required elements under § 717.19(a)(1)?(6), including the non-discrimination statement.
3. All current residents have been re-provided the updated Resident Rights document and have signed a new written acknowledgement confirming they received notice of their full rights (including the non-discrimination provision). Signed acknowledgements have been placed in each resident's individual record.
4. Going forward, every new resident will receive the updated Resident Rights document and sign the acknowledgement form at or before the beginning of residency (as required by § 717.19(b) and related intake requirements). The form is now a mandatory part of the intake packet.
Method and Frequency of Monitoring:
The House Manager will review every applicable resident record (new admissions within 48 hours of arrival and discharged/ended residency records within 7 days of departure) to verify that the required documentation is complete, signed, and present in the file.
In addition, the House Manager will conduct a formal monthly audit of all active and recently closed resident records to confirm ongoing compliance. Any deficiencies identified will be corrected immediately and documented. Results of the monthly audit will be recorded in the house compliance log and reviewed during staff meetings. |
? 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 two of seven records reviewed, the facility failed to complete the following documents, 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.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Corrective Action Taken/To Be Taken. A comprehensive Beginning of Residency / Intake Packet has been developed that contains every required element of § 717.22(b) in one signed document (attached).
2. The packet includes:
- Basic personal data (name, DOB, demographics, medical information the resident chooses to disclose, drug & alcohol history, medical contacts, emergency contact)
- Consent to residency
- Disclosure of criteria for beginning and ending residency
- Full resident orientation covering all six required topics (house rules + return-time method, fee schedule/lease, supports & referrals, financial policies, location of emergency procedures & contacts, medication policies)
- Disclosure of when staff may notify the emergency contact
- Final overall acknowledgement with checkboxes and dual signatures (resident + staff) dated within 24 hours of arrival
3. All current residents who lacked complete documentation (including the two records cited) will be (or have been) completed using the new packet and the signed forms placed in their individual records.
4. Effective immediately, every new resident will complete this full packet within 24 hours of arrival. Completion is verified by the House Manager / Compliance Officer before the resident's file is considered complete.
Method and Frequency of Monitoring:
The House Manager will review every applicable resident record (new admissions within 48 hours of arrival and discharged/ended residency records within 7 days of departure) to verify that the required documentation is complete, signed, and present in the file.
In addition, the House Manager will conduct a formal monthly audit of all active and recently closed resident records to confirm ongoing compliance. Any deficiencies identified will be corrected immediately and documented. Results of the monthly audit will be recorded in the house compliance log and reviewed during staff meetings. |
§ 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 three of four discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.Resident # 4 was admitted on January 30, 2026, with an unknown discharge date. There was no documentation of an end to residency in the resident record.Resident # 6 was admitted on February 10, 2026, with an unknown discharge date. There was no documentation of an end to residency in the resident record.Resident # 7 was admitted on January 3, 2026, with an unknown discharge date. There was no documentation of an end to residency 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 Taken/To Be Taken. A standardized Notification of Decision to End Residency form has been created that fully complies with § 717.23(a), (b), and (c) (attached).
The form includes:
- Written notice of the decision to end residency
- Required statement of the reason
- Required timeframe for ending residency
- Clear opportunity for the resident to request reconsideration before the decision takes effect (§ 717.23(b))
- A separate section for voluntary endings by the resident (who is not required to give a reason ? § 717.23(c))
- Signature lines for resident and staff, plus a house-record section to document delivery and filing
2. For the three cited residents (#4, #6, and #7) whose records lacked any end-of-residency documentation, the house has (or will immediately) complete retrospective documentation to the extent possible, including best available discharge dates, and place a completed form or explanatory note in each record acknowledging the prior gap and the corrective action taken.
3. Effective immediately, no resident will leave the house (voluntarily or involuntarily) without a completed and signed Notification of Decision to End Residency form being placed in the resident's individual record on or before the ending date.
4. Staff have been (or will be) trained on the new form and the requirement to provide written notice that includes reason + timeframe + reconsideration opportunity.
Method and Frequency of Monitoring:
The House Manager will review every applicable resident record (new admissions within 48 hours of arrival and discharged/ended residency records within 7 days of departure) to verify that the required documentation is complete, signed, and present in the file.
In addition, the House Manager will conduct a formal monthly audit of all active and recently closed resident records to confirm ongoing compliance. Any deficiencies identified will be corrected immediately and documented. Results of the monthly audit will be recorded in the house compliance log and reviewed during staff meetings. |
§ 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 four of four 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 #4 was admitted on Resident # 4 was admitted on January 30, 2026, with an unknown discharge date. There was no notification to the emergency contact provided in the resident record.Resident #5 was admitted on May 20, 2025, and discharged May 29, 2026. There was no notification to the emergency contact provided in the resident record.Resident # 6 was admitted on February 10, 2026, with an unknown discharge date. There was no notification to the emergency contact provided in the resident record.Resident # 7 was admitted on January 3, 2026, with an unknown discharge date. 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 Taken/To Be Taken. A written Policy on Notification to Family Member or Emergency Contact has been developed and implemented that fully meets § 717.27(a). The policy specifies the methods and circumstances (including hospitalization, death, ending of residency, and failure to return as expected) for notifying the emergency contact with the resident's consent, and states that the resident may revoke consent (attached).
2. An Emergency Contact Notification Log form has been created to document every required attempt. The log captures the triggering event, consent status, date/time of attempt (to prove it was made immediately and within 12 hours), method used, outcome, and staff signature (attached).
3. For the four cited residents (#4, #5, #6, and #7), retrospective documentation notes have been (or will be) placed in each record acknowledging that the required notification attempt was not made or documented at the time, and describing the corrective action taken.
4. Effective immediately, staff will complete the Emergency Contact Notification Log for every resident who ends residency or does not return as expected (unless consent has been revoked or domestic-abuse concerns apply). The completed log is placed in the resident's individual record.
Method and Frequency of Monitoring:
The House Manager will review every applicable resident record (new admissions within 48 hours of arrival and discharged/ended residency records within 7 days of departure) to verify that the required documentation is complete, signed, and present in the file.
In addition, the House Manager will conduct a formal monthly audit of all active and recently closed resident records to confirm ongoing compliance. Any deficiencies identified will be corrected immediately and documented. Results of the monthly audit will be recorded in the house compliance log and reviewed during staff meetings. |