INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, and staff schedule the facility failed to ensure that at least one person trained in CPR and first aid is onsite during project's working hours. During the hours of 8am-10am on August 30, 2026, there was not a staff at the facility trained in CPR and first aid.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Since the deficiency was identified during the site inspection, 18 program staff have been trained and certified in CPR. There are 15 remaining staff that are scheduled to complete the training in October.
The Training Coordinator has established a recurring CPR training on the 3rd Thursday of each month, in perpetuity.
Each month, the Training Coordinator will refer to the training spreadsheet to identify any staff that have a certification expiring withing the next 3 month period. They will be scheduled to attend the training scheduled for that month.
The Facility Director will complete quarterly oversight checks on this process with the Training Coordinator. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. The water in the visitor bathroom and ROD desk bathroom were recorded at 140 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The domestic hot water system has been reduced to 120 degrees. The the hot water faucets on the 1st floor are now discharging water at a temperature of 118 degrees.
The Maintenance Supervisor will monitor the domestic water heater during his monthly facility review to ensure that the temperature does not change.
Compliance to this will be overseen by the Executive Director |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilet and wash rooms by exhaust fan or window. There was not a ventilation fan or window in the ROD desk bathroom.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance supervisor has ordered a ventilation fan and necessary equipment to be installed. This will require removal of wall and ceiling components and will be completed once the required materials are available.
The Maintenance Supervisor, Ryan Copenhaver will complete this installation. Anticipated completion date for this project is 10/30/2026.
Completion of this project will be overseen by the Executive Director, Chris Runkle |