INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, True North Wellness Services 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of administrative documents from August 2025- June 2026, the facility failed to conduct unannounced fire drills in six out of eleven months reviewed.
There was no documentation of an unannounced fire drill occurring during the months of August, September, October, November and December 2025 and January 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following steps will be put into place to ensure fire drills are completed every month:
1. The Quality Improvement Coordinator will ensure monthly fire drill completion by sending emails to the Building Supervisor to complete monthly fire drill by the end of each month starting August 2026.
2. The Building Supervisor coordinates with the Facility Manager, as needed, to notify the Fire Department of monthly fire drill.
3. The Quality Improvement Coordinator will email completed fire drill log every month to the SUT OP Manager.
4. The SUT OP Manager will place completed monthly fire drill log in location specific electronic file.
5. The SUT OP Manager will notify Quality Improvement Coordinator if completed fire drill log is not received by the last week of each month.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of administrative documents, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative in four out of eleven fire drill records reviewed.
The written fire drill logs dated March through June 2026 did not include documentation of what exit route was used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following steps will be put into place to ensure fire drill logs are completed accurately each month:
1. The Quality Improvement Coordinator will update the fire drill log to include exit route used during the drill and if the method of notification activated during the drill by August 1st, 2026.
2. The Quality Improvement Coordinator will review the fire drill log updates with Building Supervisors by August 7th, 2026.
3. Building Supervisors will complete updated fire drill logs for monthly fire drill by August 31st, 2026.
4. Building Supervisors send completed fire drill logs to Quality Improvement Coordinator who then sends to SUT OP Manager.
5. SUT OP Manager will review fire drill log to ensure exit route and method of notification are completed on each log.
6. SUT OP Manager will contact Building Supervisor for missing data to ensure correct form completion.
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