INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 30, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection BYJ36701 Stop And Surrender Wayne Ministries Low Demand Dorothy 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.
|
Plan of Correction
|
§ 717.17(c) LICENSURE Personnel Management
§ 717.17. Personnel management.
(c) The licensee shall maintain a personnel record for the house manager and each staff person and volunteer, which must include:
(1) Application or resume.
(2) A Pennsylvania State Police criminal history record check.
(3) Disciplinary actions.
(4) A written job description for each drug and alcohol recovery house position.
(5) Documentation of training.
|
Observations
Based on a review of personnel records, the facility failed to provide a complete personnel record for employee # 2, that must include:
(1) Application or resume.
(2) A Pennsylvania State Police criminal history record check.
(3) Disciplinary actions.
(4) A written job description for each drug and alcohol recovery house position.
(5) Documentation of training.
Employee # 2 was hired on April 1, 2026, and was still employed at the time of the inspection. There was not an application or resume, criminal history check, or job description documented.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
POC
717.17 Personnel Management. (c) The licensee shall maintain a personnel record for the house manager and each staff person and volunteer, which must include: (1) application or resume. (2) Pennsylvania State Police criminal history record check. (3) disciplinary actions. (4) a written job description for each drug and alcohol recovery house position. (5) documentation of training.
Before hiring, all new staff shall provide a resume. The HR staff or the hiring staff will ensure the new hire has or/and completed the following: (1) filled out an application, (2) a Pennsylvania State Police criminal history record check, (3) disciplinary actions, (4) a written job description for each drug and alcohol recovery house position, (5) documentation of training, before the official start of work.
All documents must be completed upon hiring or within the days of training to complete the hire process for personnel records and to give to the HR staff or Director. Failure to provide the following documentation can affect the hiring decision.
|
§ 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.
|
Observations
Based on two of two applicable discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.
Resident #6 was admitted on April 6, 2026, and was discharged April 27, 2026. There was no documentation of an end to residency in the resident record.
Resident #7 was admitted on April 8, 2026, and was discharged April 14, 2026. 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.
|
Plan of Correction
POC
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.
PROCEDURE
Before the decision is made to end residency, a verbal warning is given, then followed by a written warning (an incident report). Final resort is to end residency (discharge).
a) Staff will give a verbal warning to correct/change area(s) of concern.
b) If the concerns continue, staff will issue a written warning (an incident report) for areas of improvement and a timeframe to correct/change the concerns.
c) If concerns continue after the incident report, the last result is to discharge.
The infractions that lead to immediate discharge are:
1. Using any type of illicit mind-altering substances on the premises.
2. Any form of threats or physical assault towards self, staff, or others.
3. Suicide attempt or verbal intent will be referred to a HLOC
This corrective action plan will go in effect on Monday, June 1, 2026.
|
§ 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.
|
Observations
Based on two of eight resident records reviewed, the facility failed to provide documentation specifying the methods and circumstances including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent and that the resident may revoke consent to provide notice to the emergency contact in accordance with 717.27 (a).
Also
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 in accordance with 717.27 (b).
Resident #6 was admitted on April 6, 2026, and was discharged April 27, 2026. There was no documentation specifying the methods and circumstances of notifying the emergency contact or notification of the resident ending residency to the emergency contact provided in the resident record.
Resident #7 was admitted on April 8, 2026, and was discharged April 14, 2026. There was no documentation specifying the methods and circumstances of notifying the emergency contact or notification of the resident ending residency to the emergency contact provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
POC
717.27 Notification to family contact or emergency contact. (a) the licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the residents hospitalization or death, for notifying the residents emergency contact with the residents 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 residents 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.
POLICY:
Upon completing admissions intake, residents are asked to provide an emergency contact for any emergencies, AWOL, and/or discharge. The resident has the right to refuse an emergency contact. If the resident refuses to list an emergency contact, it must be written on the provided emergency contact form and signed by the resident and by a witnessing staff member on duty. The resident has the right to change or remove the emergency contact at any given time.
(An updated emergency contact form must be completed and added to the file for update.)
PROCEDURE IF A CASE OF EMERGENCY, AWOL, and/or DISCHARGE
1. Once notification is received of an emergency or a resident's failure to return to the site, a written incident report must be completed by the staff on duty.
2. All consented parties must be notified, including the emergency contact (unless clients have refused), by the staff on duty immediately or within 12 hours. Any attempts or contact made with the resident's emergency contacts should be documented in the written incident report, including the dates and times.
3. This documentation should be stored in the resident's file and sent out to all necessary parties.
This corrective action plan will go in effect on Monday, June 1, 2026.
|
§ 717.29(d)(1)(v)(C) LICENSURE Physical plant standards - Sleep accomodation
§ 717.29. Physical plant standards.
(d) Sleeping accommodations.
(1) Each drug and alcohol recovery house bedroom must have the following:
(v) At least 50 square feet of floor space per resident measured wall to wall in each shared bedroom with bunk beds. Bunk beds must:
(C) Be equipped with securely attached railings on each open side and open end of the bunk.
|
Observations
Based on a physical plant inspection, the facility failed to provide a bunk bed with securely attached railing on each open side of the bunk. Bunk beds on the third floor did not have a railing.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
POC
717.29 Physical plant standards. (d) each drug and alcohol recovery house bedroom must have the following: (v) at least 50 square feet of floor space per resident measured wall to wall in each shared bedroom with bunk beds. Bunk beds must: (c) be equipped with securely attached railings on each open side and open end of the bunk.
Staff will conduct a physical plants inspection in all bedrooms to check and ensure all bunks have rails on each open side and open end of the bunk.
All bunks that are without the rails, will be now added by maintenance.
Moving forward, if the facility adds any more bunk beds to the site, maintenance will ensure that all bunks have railings on each open side and the open end of the bunk.
This corrective action plan is in effect currently. With the expected completion date by Monday, June 15, 2026.
|