INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Reset BC 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff records, the facility failed to ensure that Counselors received at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment in one of one applicable record.
Staff #2 was hired to the position of counselor on November 18, 2024 and was in this position at the time of review. Staff #2 was due to receive 4 hours of TB/STD training no later than November 18, 2025. Staff #2 completed 4 hours of TB/STD training on November 21, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure this deficiency does not recur, the Facility Director will review the training tracking system on a monthly basis to monitor upcoming training deadlines and will provide reminders at least sixty (60) days prior to required completion dates. Compliance with mandatory training requirements will also be reviewed during routine staff supervision and the facility's internal quality assurance process to ensure all required education is completed within the regulatory timeframes. If an approved external training is unavailable before a required deadline, the Facility Director will provide the required training using Pennsylvania DDAP-approved curriculum and educational materials, when permitted by regulation. Documentation of the training, including the curriculum utilized, instructor, date of completion, attendance, and training hours, will be maintained in the employee's personnel file to demonstrate ongoing compliance with DDAP
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative records and staff interview, the facility failed to make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable. An annual report was not completed for January 2025 through December 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To correct this deficiency, the Facility Director will complete the required Annual Report and ensure it contains all information required by DDAP regulations. The completed Annual Report will be maintained at the facility and made available for public inspection upon request. The Facility Director will also publish a notice in the local newspaper informing the public that the Annual Report is available for review at the facility. To ensure this deficiency does not recur, the Facility Director has incorporated the preparation, completion, public availability, and publication of the Annual Report into the facility's annual compliance calendar and administrative policies. The Annual Report will be reviewed each year to ensure all required information is included and completed within the required timeframe. Compliance with this requirement will also be monitored through the facility's annual internal quality assurance review to verify that the 2025 Annual Report has been completed, and documentation has been maintained. The RESET BC LLC 2025 Annual Report will be published in a local newspaper on August 11, 2026. |