INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection I5766701 Surge Recovery 3 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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§ 717.18(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
Based on a review of staff records, the facility failed to provide documentation for all staff persons and volunteers to complete within ninety days of hire:
(1) Cardiopulmonary resuscitation (CPR) certification.
(2) First aid training, including training on overdose reversal
medication.
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training
using a Department approved curriculum.
(4) Fire prevention and emergency preparedness, including use of a fire
extinguisher.
Staff #9 were hired as staff on November 24, , and was still in this position at the time of the inspection. Training required within the first ninety days of hire were not provided.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Facility Name: Surge Recovery
Regulation Cited: § 717.18(c) Training
Date of Inspection: 4/9/26
Prepared By: Managing Director
Deficiency Cited
The facility failed to ensure that all staff persons and volunteers completed required training within ninety (90) days of hire, including:
1. Cardiopulmonary Resuscitation (CPR) certification
2. First Aid training, including overdose reversal medication training
3. HIV/AIDS, Tuberculosis, and Sexually Transmitted Diseases training using a Department-approved curriculum
4. Fire prevention and emergency preparedness training, including use of a fire extinguisher
Some Staff did not have documentation verifying completion of the required trainings within the required timeframe.
Surge Recovery immediately reviewed the files upon notification of the deficiency. All trainings will be completed including:
- CPR Certification
- First Aid and Naloxone/Overdose Reversal Training
- HIV/AIDS, Tuberculosis, and Sexually Transmitted Diseases Training
- Fire Prevention and Emergency Preparedness Training
Certificates of completion and all supporting documentation will be placed in personnel files upon completion.
Systemic Corrective Action
To prevent recurrence of this deficiency, Surge Recovery has implemented the following corrective measures:
1. A standardized Training Compliance Checklist has been created for all new hires and volunteers to track required trainings and due dates.
2. Management will conduct a mandatory personnel file review within the first thirty (30) days of employment and again prior to the ninety (90) day deadline to ensure all required trainings are completed timely.
3. The Executive Director and designated supervisory staff will maintain a centralized training log identifying:
o Employee hire dates
o Required trainings
o Completion dates
o Upcoming expiration or renewal dates
4. New hire orientation procedures have been updated to include immediate scheduling of all mandatory trainings upon hire.
5. Quarterly internal audits of personnel records will be conducted to ensure ongoing compliance with § 717.18 training requirements.
Date of Compliance
Surge Recovery expects full compliance with this corrective action plan by:
6/1/26
Responsible Person(s)
- Executive Director
- Managing Director / House Manager
- Administrative Staff Responsible for Personnel Compliance
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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 seven resident records reviewed, the facility failed to obtain written acknowledgement by residents that they have received notice of their rights.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION
Corrective Action Taken
Surge Recovery immediately reviewed all active resident files upon notification of the deficiency. Residents whose files did not contain written acknowledgment of receipt of resident rights were provided with the Resident Rights document and asked to sign acknowledgment forms confirming receipt and understanding of their rights.
Completed acknowledgment forms are being placed in each resident's file.
Systemic Corrective Action
To prevent recurrence of this deficiency, Surge Recovery has implemented the following corrective measures:
The admission and intake process has been updated to require completion of the Resident Rights acknowledgment form at the time of admission.
A standardized intake checklist has been implemented to ensure all required admission documents, including Resident Rights acknowledgments, are completed prior to finalizing the admission process.
Staff responsible for admissions and recordkeeping have been retrained on documentation requirements related to resident rights and file compliance.
Supervisory staff will conduct weekly audits of newly admitted resident files to verify that all required documentation, including signed Resident Rights acknowledgments, is present and complete.
Quarterly internal chart audits will be conducted by administration to monitor continued compliance with resident documentation requirements.
Date of Compliance
Surge Recovery expects full compliance with this corrective action plan by: 6/1/26
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§ 717.22(b)(5) 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:
(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 a review of seven resident records, the facility failed to complete the following documentation, which must be signed by the resident, within 24 hours of arrival to include
disclosure to the residents 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
Facility Name: Surge Recovery
Regulation Cited: Resident Admission Documentation Requirement
Date of Inspection: 4/9/26
Prepared By: Managing Director
Deficiency Cited
Based on a review of seven resident records, the facility failed to complete required documentation, signed by the resident within twenty-four (24) hours of arrival, including disclosure of the recovery house's policies and procedures regarding situations in which recovery house staff may notify the resident's emergency contact.
These findings were reviewed with recovery house staff during the licensing process.
Corrective Action Taken
Surge Recovery immediately reviewed all active resident records upon notification of the deficiency. Residents whose files did not contain properly completed and signed emergency contact notification disclosure documentation were provided the required disclosure form and signatures were obtained.
Completed documentation has been placed in each resident's record.
Systemic Corrective Action
To prevent recurrence of this deficiency, Surge Recovery has implemented the following corrective measures:
1. The admission and intake process has been revised to include mandatory completion of the Emergency Contact Notification Disclosure form within twenty-four (24) hours of resident arrival.
2. A standardized admission checklist has been implemented to ensure all required intake documentation is completed, signed, and filed timely.
3. Intake staff and supervisory personnel have been retrained regarding documentation requirements and timelines related to resident admissions and disclosures.
4. Supervisory staff will review all new admission files within twenty-four (24) hours to verify compliance with required documentation standards.
5. Quarterly internal audits of resident records will be conducted to monitor ongoing compliance with admission documentation requirements.
Date of Compliance
Surge Recovery expects full compliance with this corrective action plan by:
5/6/26
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§ 717.31(c)(4) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(4) An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of resident ' s records, an incident involving medical police being called to the facility was not reported to the department within three business days after the incident occurred.
Resident #1 was admitted on October 17, 2025, and was still active at the time of the inspection. An unusual incident requiring police presence occurred on February 18, 2026 and an unusual incident report was not filed with the department within 3 days.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Facility Name: Surge Recovery
Regulation Cited: Incident Reporting Requirement
Date of Inspection: 4/9/26
Prepared By: Managing Director
Deficiency Cited
Based on a review of resident records, an incident involving police presence at the facility was not reported to the Department within three (3) business days after the incident occurred.
Resident #1 was admitted on October 17, 2025, and remained active at the time of inspection. An unusual incident requiring police presence occurred on February 18, 2026; however, an unusual incident report was not filed with the Department within the required three-business-day timeframe.
These findings were reviewed with recovery house staff during the licensing process.
Corrective Action Taken
Upon notification of the deficiency, Surge Recovery immediately reviewed the incident involving the Resident and will complete the required unusual incident documentation. The incident report will be submitted to the Department.
Administrative and supervisory staff responsible for incident reporting were informed of the reporting deficiency and retrained on required reporting timelines and procedures.
Systemic Corrective Action
To prevent recurrence of this deficiency, Surge Recovery has implemented the following corrective measures:
1. A formal Incident Reporting Tracking Log has been implemented to monitor all unusual incidents and ensure timely reporting to the Department within required timeframes.
2. Policies and procedures regarding unusual incident reporting have been reviewed and reinforced with all supervisory and direct care staff.
3. All incidents involving police, emergency medical services, hospitalization, overdose, injury, or other reportable events will be immediately reviewed by supervisory staff to determine reporting obligations.
4. The Executive Director or designated supervisor will review all incident reports within twenty-four (24) hours of occurrence to ensure compliance with Department reporting requirements.
5. Staff training on unusual incident reporting requirements, including reporting deadlines and documentation procedures, will be conducted during orientation and annually thereafter.
6. Quarterly internal audits of incident reports and reporting logs will be completed to monitor ongoing compliance.
Date of Compliance
Surge Recovery expects full compliance with this corrective action plan by:
5/6/26
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