INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on August 26, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Michael ' s Sanctuary LLC 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of staff records, the facility failed to ensure a written individual training plan for each employee was developed annually in one of one record.
Staff #1 was hired as Project Director on January 27, 2025 and was in this position at the time of review. No individual training plan for the January 2025 through December 2025 training year was completed for Staff #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Correction to be made
An individual training plan for Project Director will be developed and signed by the Project Director to ensure compliance with §704.11(b)(1). The plan will identify the employees' training needs appropriate to their skill level, job duties, and DDAP role requirements.
1. Steps to correct the deficiency
- The Project Director's 2025 Individual Training Plan was completed on 9/5/25 and placed in the employee's personnel file.
- The Project Director reviewed all staff files to confirm that each employee has a current, signed annual training plan on record.
- A Training Plan Compliance Checklist was added to each personnel file to ensure documentation of completion, signatures, and review dates.
- The Project Director will maintain a training plan log to track annual completion and renewal dates for each staff member.
2. Plan to prevent recurrence
- The facility will implement an annual reminder system within the HR calendar to alert supervisors 30 days before each employee's training plan is due.
- The Program Director will review and update each employee's training plan during annual performance evaluations.
- The Program Director will conduct quarterly personnel file audits to ensure ongoing compliance with §704.11(b)(1).
- Results of the audits will be discussed during monthly leadership meetings, and noncompliance will result in corrective action or retraining for responsible supervisors.
3. Completion Date: 9/5/25
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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 records, the facility failed to maintain a written fire drill record for the months of February 2025 through August 2025 that included the time it took for evacuation, problems encountered, and whether the smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action Taken:
- All missing fire drill records for February through August 2025 have been recreated to the extent possible, including evacuation times, problems encountered, and smoke detector status.
- Staff were retrained on proper documentation of fire drills and the importance of including all required information.
Measures to Prevent Recurrence:
- A standardized fire drill log template has been implemented that includes fields for date, time, evacuation duration, problems encountered, and smoke detector status.
- Facility staff are required to complete the fire drill record immediately after each drill.
- Monthly audits of fire drill logs will be conducted by the Safety Officer/Administrator to ensure compliance and accuracy.
COMPLETION DATE: 9/5/25
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill log and staff interview, the facility failed to set off a fire alarm or smoke detector during each fire drill.
No documentation was found to indicate that a fire alarm or smoke detector was set off during the fire drills conducted on the following dates: February 4, 2025; March 5, 2025; April 15, 2025; May 6, 2025; June 5, 2025; July 3, 2025; August 1, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction to be made
The facility has corrected all fire drill documentation for 2025 to ensure that each record contains the required elements:
- Date and time of drill
- Evacuation duration
- Exit route used
- Number of people in the facility
- Problems encountered
- Verification that the fire alarm/smoke detector was operative
A new Fire Drill Record Form has been implemented to include these mandatory fields
Steps to correct the deficiency
1. The Safety Officer reviewed all fire drill records from February through September 2025 and updated each record to reflect on all missing information where available.
2. A revised Fire Drill Record Form was created and distributed to all staff responsible for conducting drills.
3. Training was provided on 9/5/25 to all staff on how to properly document fire drills in accordance with §705.28(d)(4).
4. The Project Director will review and sign each monthly drill record for accuracy and completeness.
Completion Date: 9/5/25
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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a review of the physical plant, the facility failed to ensure the hours of operation were displayed conspicuously to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
Post Hours of Operation: Facility will display its hours of operation in a conspicuous location visible to all visitors, such as the main entrance, reception area, and/or exterior signage.
Accessibility: Ensure that the posted hours are legible, clear, and easily readable by the public at all times.
Completion Date: 9/5/25 |