INITIAL COMMENTS
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This report is a result of an complaint investigation conducted December 9 to January 6, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the complaint investigation Stop and Surrender Wayne Ministries, Men's House, 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 investigation.
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Plan of Correction
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§ 717.17(b)(2) LICENSURE Personnel Management
§ 717.17. Personnel management.
(b) The written policies and procedures must include:
(2) Rules of conduct.
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Observations
Based on resident interviews and review of the personnel management policy, staff are not following rules of conduct specific to judging or punishing based on gender, race, sexual orientation, religion and sexual orientation.
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Plan of Correction
POC
717.17 (b) (2) Personnel Management - The written policies and procedures must include: rules of conduct.
It is the policy of "Wayne Ministries" that it will not tolerate verbal or physical conduct by any employees that harasses, disrupts, or interferes with the performance of a resident or the facility, or that creates an intimidating, offensive, or hostile environment.
Each site supervisor is responsible for maintaining a workplace free of harassment based on gender, race, sexual orientation, religion, or national origin.
Any resident who believes that an employee's actions or words constitute unwelcome harassment has a responsibility to report a grievance or complaint as soon as possible to their supervisor, the supervisor's supervisor, or the director.
All complaints of harassment will be investigated promptly and in an impartial and in as confidential a manner as possible as directed by the Supervisor with advice of Legal Counsel. In all cases, the employee is to be advised of the findings and conclusions by management.
Any employee, supervisor or manager who is found after appropriate investigation to have engaged in harassment of another employee will be subject to appropriate disciplinary action, depending on the circumstances, up to and including termination.
This corrective action plan will go into effect on Monday, March 2, 2026.
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§ 717.29(b)(3) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(3) Keep the drug and alcohol recovery house free of rodent and insect infestation.
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Observations
Based on review of the physical plant inspection, the recovery house has failed to keep the kitchen of insect infestation.
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Plan of Correction
POC
717.29(b) (3) Physical plant standards ? Building interior, exterior, and grounds. The licensee shall: keep the drug and alcohol recovery house free from rodent and insect infestation.
1. Participants maintain the cleanliness of their space and the general tidiness of common shared areas. On-site house managers are to monitor, exemplify, and, if needed, assist.
2. Chores are outlined for residents and assigned by the house manager on-site.
3. The house manager on-site monitors residents' chores for completion in the morning and evening, including the kitchen, bathrooms, bedrooms, and shared spaces.
4. A licensed and insured pest and wildlife control service (Humane Wildlife and Pest Control, Inc.) provides monthly visits for extermination and pest control to maintain a pest-free environment, along with the mandatory GI cleanings. The facility receives pest extermination services each month to ensure free from insect infestation.
The house managers will continue to provide and rotate these lists of house chores for participants to keep the facilities clean and to help residents develop essential daily living skills for independent living.
This action plan will be in effect on Monday, March 2nd, 2026.
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§ 717.29(e)(2) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(2) Provide a sink, a wall mirror, a soap dispenser and either individual towels, paper towels, or a mechanical dryer in each bathroom.
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Observations
Based on review of the physical plant inspection, the recovery house does not supply individual towels, paper towels, or a mechanical dryer in each bathroom.
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Plan of Correction
717.29 (e) (6) Physical plant standards ? Bathrooms. The licensee shall: provide a sink, a wall mirror, a soap dispenser, and either individual towels, paper towels, or a mechanical dryer in each bathroom.
PROCEDURE
The on-site house manager staff will evaluate when supplies are needed through a visual walk-through assessment and communication with residents in the facility. Staff are prompt to request supplies when items are running low.
1. The on-site house manager will be required to complete the detailed supply list for the specific site. Staff must date the supply list when submitting the request to management and keep a copy for house records.
2. Once the supply list is received, management will have the order filled within 24-72 hours.
3. Once the on-site house manager receives the supplies, they will be required to log and store them in the appropriate location and to date the initial supply list with the dates when the items were received.
4. If the house manager staff have an issue receiving supplies, they are instructed to contact the management supervisor, the Director.
This corrective action plan will go into effect on Monday, March 2, 2026.
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§ 717.29(e)(6) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on review of the physical plant inspection and interview with staff and residents, the recovery house does not supply toilet paper at all times.
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Plan of Correction
717.29 (e) (6) Physical plant standards ? Bathrooms. The licensee shall: provide toilet paper at each toilet at all times.
PROCEDURE
The on-site house manager staff will evaluate when supplies are needed through a visual walk-through assessment and communication with residents in the facility. Staff are prompt to request supplies when items are running low.
1. The on-site house manager will be required to complete the detailed supply list for the specific site. Staff must date the supply list when submitting the request to management and keep a copy for house records.
2. Once the supply list is received, management will have the order filled within 24-72 hours.
3. Once the on-site house manager receives the supplies, they will be required to log and store them in the appropriate location and to date the initial supply list with the dates when the items were received.
4. If the house manager staff have an issue receiving supplies, they are instructed to contact the management supervisor, the Director.
This corrective action plan will go into effect on Friday, February 27th, 2026.
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