INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection MC3M6701 Step by Step 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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§ 717.12 LICENSURE Refusal or revocation of license
§ 717.12. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the
Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the drug and alcohol recovery house.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or
attempting to obtain a license.
(6) Lending, borrowing or using the license of another drug and alcohol recovery house.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing residents at the drug and alcohol recovery house.
(9) Continued noncompliance in disregard of this part.
(10) Operating a drug and alcohol recovery house that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the applicant or licensee by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the drug and alcohol recovery house to correct deficiencies.
(c) If the drug and alcohol recovery house does not correct the deficiencies within the specified time, the Department will officially notify the applicant or licensee that it shall show cause why its license should not be denied or revoked under 1 Pa. Code § 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. The applicant or licensee shall file a written request within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code § 35.14.
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Observations
Based on the previous and current technical assistance provided, prior citations the recovery house failed to comply with a plan of correction approved by the Department, unless the Department approves and extension or modification of the plan of correction and failed to comply with a directive issued by the Department.
1. Failure to complete and return required documentation of data collection form
2. Failure to complete required documentation of attestation form
3. Resident rights missing in records
4. Incomplete Data Collection
5. No contact made to family member or emergency contact
6. No resident roster being maintained
7. Faulty fire extinguisher inspection tags
8. Physical plant is not kept in good repair
9. Bedroom furniture is not in good repair
10. Does not maintain referral documentation or provide referrals.
11. No notifications of decision to end residency
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Plan of Correction
The plan of correction for citation 0153 - The owner will oversee that the above-mentioned deficiencies are corrected and implemented by 2/26/26. The owner is responsible to ensure that these defic
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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 review of the resident records, the recovery house failed to provide resident rights.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of 2/18/2026 We are now using consent to residency form that includes residents' rights. It is the last page of our resident handbook
1. It has been reviewed with house lead and house manager to complete with house residents upon beginning of residency.
2. The house lead is responsible for making sure form is completed and acknowledged.
3.The form is expected to be done with both resident and house lead and put into resident binder.
4. The house manager will be completing an inspection on all new binders weekly
that includes resident's rights form.
Date of correction completed 2/18/2026
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§ 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
Based on request to review discharge records the recovery house failed to provide discharge records
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The plan of correction Step by Step Recovery has now implemented an excel spreadsheet for all new residents for our resident roaster and also our now using One Step Software . The completion of all resident is now in place .
The responsibility of this task will be the GM
Completion date 2/19/2026
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§ 717.20(a)(3) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(3) Referrals to and from the drug and alcohol recovery house, if
applicable.
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Observations
Based on review of the resident records and interview with the house manager, the recovery house failed to provide referrals to and from the recovery house.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of 2/18/2026 We are now using the referral form that includes. It is now part of our resident handbook.
1. It has been reviewed with house lead and house manager to complete with house residents upon beginning and ending of residency.
2. The house lead is responsible for making sure form is completed with resident and stored induvial binders.
3. The house manager will be completing an inspection on all binders weekly
that includes form.
Date of correction completed 2/18/2026
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§ 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
Based on review of the resident records, the recovery house failed to have a resident roster.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction:
Plan of Correction:of citation 0220 is as follows
The plan of correction Step by Step Recovery has now implemented an excel spreadsheet for all new residents for our resident roaster and also our now using One Step Software . The completion of all resident is now in place .
The responsibility of this task will be the GM
Completion date 2/10/26 |
§ 717.22(b)(3)(vii) 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:
(3) Basic personal data including:
(vii) Emergency contact.
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Observations
Based on review of resident records the recovery house failed to collect full basic personal data.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of 2/18/2026 We are now using consent to residency form that includes emergency contact information. It is the last page of our resident handbook
1. It has been reviewed with house lead and house manager to complete with house residents upon beginning of residency.
2. The house lead is responsible for making sure form is completed and acknowledged.
3.The form is expected to be done with both resident and house lead and put into resident binder.
4. The house manager will be completing an inspection on all new binders weekly
that includes the emergency contact section is completed. House manager will also check in with house lead when someone has left the facility.
5.The house lead is responsible to notify emergency contact and update house manager and make sure it is noted on the emergency notification form.
Date of correction completed 2/18/2026
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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 review of the resident records the recovery house failed to provide a written notification to the resident stating the decision to end residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As of 2/18/2026 We are now using notification to end residency form.
1. It has been reviewed with house lead and house manager to complete with house residents upon discharge.
2. The house lead is responsible for making sure form is updated and emergency contacted is notified with 12 hours of departure of facility.
3.The form is expected to be done with both resident and house lead and put into discharge binder
Date of correction completed 2/18/2026
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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 a review of resident records, the recovery house failed to make at least one attempt to notify the resident ' s emergency contact in accordance with subsection 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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
0310 - As of 2/14/26 the recovery house has begun documenting when an emergency contact is notified with 12 hours of any administrative discharges, no return to the house, hospitalization and death. The emergency contact information is gathered at the time of admission. When emergency contact information must be notified it will be documented in the record stating date and time, if message was left or spoken to someone. The owner is responsible for ensuring the call to the emergency contact is completed within 12 hours by reaching out to house manager or house lead when notified of discharge and ensuring that the contract is made. The owner will ensure this does not recur by maintaining communication with house manager and house leads 3 times a week. |
§ 717.29(b)(1) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(1) Keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
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Observations
Based on review of the physical plant inspection the recovery house failed to
keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The plan of correction of the physical grounds and interior has been corrected.
Which implemented a rule that residents must sign up weekly for our GI duty which the resident is responsible for that week. The house lead will check the GI checklist form that we have made a mandatory form that must be signed off by the house lead and the resident responsible for GI assigned to resident.
Which will change weekly ,we also have a chore list that is signed off weekly by H and resident. This is part of are weekly chore and deep cleaning on GI day which now when House Manager does there weekly check list form for will make sure the outside as well as inside the facility is neat and clean.
This will take into affect as of 2/19/26
Responsible person is the House Manager. |
§ 717.29(d)(1)(iii) 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:
(iii) A storage area for clothing for each resident.
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Observations
Based on review of the physical plant inspection the recovery house failed to
keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The plan of correction to make sure during pur monthly check list on each house.That all furniture, beds ,one dresser. We also have the house lead to check in with the GM when new resident has arrived so the new intake packet , there pillows, sheets and blankets as well as new illow and towels and washcloths were given at time of arrival
The person responsible is the house lead.
And also GM responsible to make sure furniture needs repair, replacing.we also have a matinee request forms in our forms for all residents to have access too.
The completetion will take place 2/14/2026 |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
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Observations
Based on a review of the fire extinguishers located throughout that property, the recovery house failed to have fire extinguishers inspected and approved annually by the local fire department or fire extinguisher company.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The plan of correction Step by Step
We will visit a certified inspection station, to have every single fire extinguisher from each house inspected by a certified fire extinguisher inspector.
We will conduct this inspection annually.
Now, it's evident that this must be done annually. Therefore, the fire extinguishers will be taken to the Upper Darby inspection station, which is a certified inspection station.
The person responsible is the House Lead we will do monthly checks and implemented a form which the General Manager will sign off on when the health and safety walk throughs are done on monthly basis
Completion date 2/14/2026
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