INITIAL COMMENTS
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This report is a result of an renewal on-site licensure inspection conducted on October 17, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 04O56701 Delco House LLC was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
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Plan of Correction
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? 717.15(c) LICENSURE House Manager
§ 717.15. House Manager.
(c) The house manager shall complete at least 6 hours of training in one or more of the following areas within 6 months of becoming house manager, and annually thereafter:
(1) Fiscal policy.
(2) Administration.
(3) Program planning.
(4) Quality assurance.
(5) Program licensure.
(6) Personnel management.
(7) Confidentiality.
(8) Ethics.
(9) Trends in drug use and misuse.
(10) Developmental psychology.
(11) Interaction of addiction and mental illness.
(12) Cultural awareness.
(13) Sexual harassment.
(14) Relapse prevention.
(15) Substance use disorders.
(16) Peer support or mutual aid groups.
(17) Best practices for medication control and self-administration.
(18) Infection control.
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Observations
The recovery house failed to have the house manager complete 6 hours of training within 6 months of becoming house manager and annually thereafter.
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Plan of Correction
The house manager is scheduled to complete the required 6 hours of training by Dec 13th 2025. All training will be documented, and certificates will be placed in a the personnel file upon completion.
Effective Immediately:
Delco House will maintain a training tracking log for all staff, including due dates for the six-hour annual training requirement
The house manager will be required to complete their six hours of training with the first 90 days of the calendar year to ensure compliance well ahead of deadlines.
No staff will continue in their role without current training on file |
§ 717.18(c)(1) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(1) Cardiopulmonary resuscitation (CPR) certification.
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Observations
The recovery house failed to ensure that all staff and volunteers complete cardiopulmonary resuscitation certification within 90 days of their start date.
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Plan of Correction
the house manager enrolled in CPR training online. The house manager finished the online portions which took about 2 hours or so and now has the in person portion scheduled for nov 22nd at 9:00am. once it is completed the house manager will email you the certification. |
§ 717.18(c)(2) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(2) First aid training, including training on overdose reversal medication.
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Observations
The recovery house failed to ensure that all staff and volunteers complete first aid training, including training on overdose reversal medication within 90 days of their start date.
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Plan of Correction
The house manager completed the certification training for the first aid and overdose reversal medication and will email you the certificate. this was completed on 11/10/2025
Effective immediately, Delco house will implement the following procedure.
All new staff will complete the first aid and overdose reversal training within 30 days of hire, ensuring compliance well before the 90-day requirement.
proof of training certificate will be collected before they are allowed to independently perform any duties.
a training compliance log will be maintained and reviewed monthly to ensure all staff remain current. |
§ 717.18(c)(3) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
The recovery house failed to ensure that all staff and volunteers complete HIV/AIDS, tuberculosis and sexually transmitted diseases using a department approved curriculum within 90 days of their start date.
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Plan of Correction
The house manager has completed the hiv/aids, tb, and std trainings and received the certificate. it will be email to you asap.
Effective Immediately, Delco House will implement the following procedure:
All new staff must complete Hiv/Aids, tuberculosis and sexually transmitted diseases within 30 days of hire, ensuring compliance well before the 90 - day requirement.
proof of training (certificate) will be collected before they are allowee to independently perform duties.
A training compliance log will be maintained and reviewed monthly to ensure all staff remain current |
§ 717.18(c)(4) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(4) Fire prevention and emergency preparedness, including use of a fire extinguisher.
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Observations
The recovery house failed to ensure that all staff and volunteers complete training for fire prevention and emergency preparedness, including use of a fire extinguisher within 90 days of their start date.
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Plan of Correction
The house manager has completed the training for fire prevention and emergency preparedness, including use of a fire extinguisher and received the certificate. it will be email to you asap.
Effective Immediately, Delco House will implement the following procedure:
All new staff must complete training for fire prevention and emergency preparedness, including use of a fire extinguisher within 30 days of hire, ensuring compliance well before the 90 - day requirement.
proof of training (certificate) will be collected before they are allowed to independently perform duties.
A training compliance log will be maintained and reviewed monthly to ensure all staff remain current |
§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
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Observations
The recovery house failed to maintain an individual record for each resident which must include all records obtained under 717.22.
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Plan of Correction
All current resident records stored in the recovery house's secure electronic documentation system were reviewed as of 11/15/2025. Any missing documentation required under 717.22 (identification, intake forms, agreements, incident reports, etc.) has been updated and completed in the system. all resident files are now complete and available for review upon request.
Effective Immediately:
Delco House will use the existing electronic record - keeping software as the official resident file system. the procedures will be implemented.
A resident file checklist will be completed at intake to ensure all required documents under 717.22 are entered into the system.
The house manager will complete a monthly audit fo each active resident file to confirm documentation remains complete and up to date.
Any new information (incidents, notices, agreements, discharges, etc) will be uploaded to the resident record within 24 hours of occuring.
Resident files will be produced for DDAP review either electronically or in person upon request. if an electronic export is unavailable, records will be printed or displayed onsite for inspection.
owner Eric Majcher, will oversee maintenance of all individual resident records, ensure monthly audits are completed, and verify that all required documents are uploaded and organized in the resident software system. |
§ 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
The recovery house failed to maintain a resident roster that identifies the date of each resident's beginning and end or completion of residency.
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Plan of Correction
All current resident roster records stored in the recovery house's secure electronic documentation system were reviewed as of 11/15/2025. Any missing documentation required under 717.22 (each resident's beginning and end or completion of residency) has been updated and completed in the system. all resident files are now complete and available for review upon request.
Effective Immediately:
Delco House will use the existing electronic record - keeping software as the official resident file system. the procedures will be implemented.
A resident file checklist will be completed at intake to ensure all required documents under 717.22 are entered into the system.
The house manager will complete a monthly audit fo each active resident file to confirm documentation remains complete and up to date.
Any new information will be uploaded to the resident record within 24 hours of occurring.
Resident files will be produced for DDAP review either electronically or in person upon request. if an electronic export is unavailable, records will be printed or displayed onsite for inspection.
owner Eric Majcher, will oversee maintenance of all individual resident records, ensure monthly audits are completed, and verify that all required documents are uploaded and organized in the resident software system.
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§ 717.30(b)(2) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(2) Maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
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Observations
The recovery house failed to ensure that all fire ladders were securely affixed to the house.
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Plan of Correction
as of 11/05/2025, all fire escape ladders on all applicable floors have been securely affixed to their designated mounting brackets by the house manager and moved the dresser that was in front of the window so there is no obstruction in front of the window.
Photographs documenting the corrected installation have been taken and are available upon request.
Effective Immediately:
a fire safety equipment checklist will be used to verify that all fire escape ladders remain properly affixed at all times.
The house manager will conduct monthly inspections of every fire ladder.
All new residents will shown the location and proper use of the affixed ladders during their orientation.
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