INITIAL COMMENTS
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This report is a result of an off-site telehealth-only licensure renewal inspection conducted on September 9, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the off-site inspection, Path to Peace 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(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to have staff of the project complete a training needs assessment the last 60 days of each calendar year or within 60 days of initial hire date, per facility policy, in one out of one record reviewed.
Employee #1was hired on December 5, 2025, as the project director, facility director, and counselor, and was still current in those positions. There was no documentation of a training needs assessment in the personnel record at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Path to Peace will ensure that a staff training needs assessment is completed and maintained in the personnel file for each employee in accordance with 28 Pa. Code § 704.11(a)(1) and agency policy. The Project Director will complete and document the required training needs assessment for the employee identified during the inspection. The assessment will identify training needs based on the employee's current job responsibilities, qualifications, and professional development needs.
The agency will maintain a tracking system to ensure that training needs assessments are completed during the last 60 days of each calendar year and within 60 days of a new employee's hire date, as applicable. The Project Director will be responsible for ensuring compliance and maintaining the required documentation in personnel files.
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to complete an overall training plan for agency personnel by March 1 of each year, per the facility policy.
There was no documentation of an overall plan for staff training needs completed at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Path to Peace will develop and maintain a written overall staff training plan addressing the training needs identified through staff training needs assessments. The plan will identify required and recommended training, applicable timelines, and the process for monitoring completion.
The Project Director will complete the agency's overall staff training plan and maintain it with the agency's staff development records. Moving forward, the agency will review and update the overall training plan annually and ensure that it is completed by March 1 of each calendar year, in accordance with agency policy and 28 Pa. Code 704.11(a)(2).
The Project Director will be responsible for reviewing training documentation and monitoring compliance with established deadlines. |
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 personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level within 30 days of employment and annually thereafter, per facility policy, in one out of one employee record reviewed.
Employee #1 was hired on December 5, 2025, as the project director, facility director, and counselor, and was still in the position as of the date of the inspection. There was no documentation of an individual training plan in the personnel record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Path to Peace will ensure that a written individual training plan is developed and maintained for each employee based on the employee's job responsibilities, qualifications, and identified training needs. The Project Director will complete the individual training plan for the employee identified during the inspection, with input from the employee and supervisor, and maintain the documentation in the personnel file.
The agency will implement a tracking process to ensure that individual training plans are completed within 30 days of employment and annually thereafter, as required by 28 Pa. Code 704.11(b)(1). The Project Director will review personnel records periodically to verify that required training plans are present, current, and appropriately documented. |