INITIAL COMMENTS
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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 30PV6701 Stop And Surrender Wayne Ministries 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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§ 717.17(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.
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Observations
Based on a review of personnel records, the facility failed to provide a complete personnel record for employees 8 and 9, 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 # 8 was hired on August 26, 2025, and was still employed at the time of the inspection. There was not a criminal history check or job description documented.
Employee # 9 was hired on May 20, 2025, and was still employed at the time of the inspection. There was not a criminal history check or job description documented.
These findings were reviewed with the recovery house staff during the licensing process.
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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.
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§ 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
Based on a review of personnel records, the facility failed to provide documentation for all staff persons and volunteers to complete the following within 90 days of becoming an employee or volunteer:
(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.
Employee # 8 was hired on August 26, 2025, and was still employed at the time of the inspection. There was no documentation of HIV/AIDS, tuberculosis and sexually transmitted diseases training of fire prevention and emergency preparedness, including use of a fire extinguisher.
Employee # 9 was hired on May 20, 2025, and was still employed at the time of the inspection.
These findings were reviewed with the recovery house staff during the licensing process.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
POC
717.18 Training. (c) in addition to training identified and provided under subsection (a) staff persons and volunteers shall complete the following within the 90 days of becoming an employee or volunteer: (4) fire prevention and emergency preparedness, including use of a fire extinguisher.
Upon hiring, HR will provide a mandatory "training course list" to all new staff. The following trainings must be completed within 90 days of hire date and will be reviewed during 90-day supervision.
1. Cardiopulmonary resuscitation (CPR) certification.
2. First Aid training, including training on overdose reversal.
3. HIV/AIDS, tuberculosis and sexually transmitted disease training using a department approved curriculum.
4. Fire prevention and emergency preparedness, including use of a fire extinguisher.
All the listed trainings must be completed within 90 days of hire for personnel records during supervision evaluation and will given to the HR staff or Director.
Failure to complete trainings, could result in disciplinary action or termination.
This corrective action plan is in effect currently. With the expected completion date by Monday, June 15, 2026.
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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 two of seven resident records reviewed, the facility failed to obtain written acknowledgement by residents that they have received notice of their rights.
Resident # 2 was admitted on September 9, 2025, and was still active at the time of the inspection. There was no acknowledgement by residents that they have received notice of their rights.
Resident # 7 was admitted on January 13, 2026, and was discharged March 31, 2026. There was no 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
POC
717.19 Residents Rights. (b) the licensee shall obtain written acknowledgement by residents that they have received notice of their rights.
PROCEDURE
a. Residents will be informed of their rights and responsibilities upon intake and admission into the program. A resident handbook will be provided to each resident listing the residents' rights.
b. Resident Rights will be reviewed with resident, accompanied by staff on duty to ensure understanding.
c. After ensuring the rights are understood, a confirmation page will be signed and added to resident charts for completion.
I have reviewed a copy of the resident's rights and understand the right I have. I have _____ accepted or _____ refused a copy of the residents' rights.
RESIDENTS SIGNATURE ___________________________________ DATE _____________
STAFF SIGNATURE _______________________________________ DATE ______________
This corrective action plan is in effect currently. With the expected completion date by Monday, June 15, 2026.
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§ 717.22(b)(4) 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:
(4) Consent to residency.
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Observations
Based on two of seven applicable resident records reviewed, the facility failed to provide a consent to residency which must be signed by the resident within 24 hours.
Resident # 2 was admitted on September 9, 2025, and was still active at the time of the inspection. There was not a consent to residency provided in the resident record.
Resident # 7 was admitted on January 13, 2026, and was discharged March 31, 2026. There was not a consent to residency 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
POC
717.22(b)(2)(ii) Beginning of Residency. (b) the licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival: (4) consent to residency.
PROCEDURE
a. Residents will be informed of the policy and procedure upon intake and admission into the program, staff on duty will also provide the resident with a copy of the resident handbook.
b. After the resident is in agreeance of the policies and procedures, the resident must sign the consent to residency.
c. A copy of the signed consent to residency will be added to the resident chart for confirmation.
I am consenting to residency. I have _____ accepted or _____ refused a copy of the consent to residency.
RESIDENTS SIGNATURE ___________________________________ DATE _____________
STAFF SIGNATURE _______________________________________ DATE ______________
The Case Manager will be required to ensure that each new resident consent to residency form is signed within 24 hours of arrival.
This corrective action plan is in effect currently. With the expected completion date by Monday, June 15, 2026.
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§ 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 one of three discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.
Resident #7 was admitted on January 13, 2026, and discharged March 31, 2026. There was no documentation of an end to residency including notifying the resident of the opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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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.
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§ 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 two of three 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 #6 was admitted on January 27, 2026, and was discharged April 15, 2026. There was no notification to the emergency contact provided in the resident record.
Resident #7 was admitted on January 13, 2026, and discharged March 31, 2026. 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
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.
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