INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2025 through June 17, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Family House 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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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, the facility failed maintain all structures, fences, and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
At the time of the physical plant inspection, which was conducted at approximately 10:45am on June 17, 2025, there was a wood seating table in the children's playground area that had rusty nails exposed and sticking up from the top ends of the table.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/17/2025, the wooden seating table was removed from the playground area. All exposed nails and hazardous debris were immediately discarded in accordance with facility safety procedures.
The Program Director or designee will conduct and document a daily inspection of the playground using the Playground Safety Checklist to ensure all structures, fences, and equipment remain free of hazards. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the grounds of the facility were clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
At the time of the physical plant inspection, conducted at approximately 10:45am on June 17, 2025, there was trash on the ground near the child rock-climbing wall and there was a dirty Styrofoam bowl in the children's playhouse. Additionally, there was a broken, metal umbrella pole leaning up against the side of the building in the playground yard. Also, there was a child's play tarp/tunnel lying on the playground floor and it appeared to have moss, dirt, grime and standing water on it.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/17/2025 the children's playground area was cleared of all trash (tarp, styrofoam bowl, and umbrella pole). Items were discarded immediately.
By 8/15/2025, the Program Director will develop a standardized Playground Safety Checklist that includes inspection points for all structures, fencing, equipment, and potential hazards. All direct care and maintenance staff will be trained on the new checklist and hazard reporting protocols by 8/29/2025, prior to implementation. Training will include hazard recognition, immediate corrective actions,and documentation requirements.
Program Director will review completed checklists by the 15th of each month to confirm inspections are consistently performed and any hazards are addressed within 24 hours.
Quality Assurance will perform quarterly audits of playground safety documentation. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to keep food cold food at or below 40 hot food at or above 140 and frozen food at or below 0
At the time of the physical plant inspection, conducted at approximately 10:45am on June 17, 2025, the freezer, located in the kitchen, had a registered, internal temperature reading of 15 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Refrigeration contractor contacted to inspect and/or repair (as needed) freezer.
Assistant Director will follow-up to ensure internal temperature falls within required compliance to maintain optimal food quality at all times.
Staff will conduct weekly refrigeration temperature checks and will notify management of temperature changes that will affect food quality. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in two of fifteen personnel records reviewed.
Employee #4 was hired as a counselor on February 12, 2025. There was no documentation in the record indicating the fire extinguisher training was completed as of the date of the inspection.
Employee #9 was hired as a parent support on June 11, 2024. There was no documentation in the record indicating the fire extinguisher training was completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will ensure all staff receive and/or have access to all required trainings.
Director will ensure all managers have access to training material as a back-up to ensure there are no barriers to employees acquiring the needed trainings.
Employee #4 completed the required training on 6/18/2025.
Employee #9 has been notified about and will be scheduled with the Assistant Director to complete the training.
Assistant Director will work to remove all barriers that may interfere with the employees capability to complete the training in a timely manner. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's July 2024 through June 2025 fire drill logs and a physical plant inspection, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was a six-month fire drill schedule (January 2025 through June 2025) posted on the wall in the main office on the first floor. According to the fire drill logs, the fire drills during the months of January, March and April 2025 were conducted on the exact date and times listed on the posted schedule; therefore, the fire drills for January, March, and April 2025 were not unannounced.
This is a repeat citation from the May 29, 2024 and July 29, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drill schedule was removed 6/17/2025 and all remaining fire drills will be unannounced, conducted on different days, different shifts, and different times.
Assistant Director will review fire drill logs to ensure they are not repetitive and filled out completely.
Director will review for compliance. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel are trained to perform assigned tasks during emergencies in two of fifteen personnel records reviewed.
Employee #4 was hired as a counselor on February 12, 2025. There was no documentation indicating the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
Employee #9 was hired as a parent support on June 11, 2024. There was no documentation indicating the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Upon Hire and yearly, staff will be trained on Fire Safety.
Staff will be informed of monthly training facilitated by the Program Director in advance to ensure they are aware and can schedule to attend.
Director will ensure all managers have access to training material as a back-up to ensure there are no barriers to employees acquiring the needed training's.
Director or designee will work to remove all barriers that may interfere with the employees capability to complete the training in a timely manner.
Director or designee will will conduct quarterly audits of employee files for compliance.
Employee #4 completed the required training on 6/18/2025.
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705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on a physical plant inspection, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks, as the facility provides custodial care services to children.
At the time of the inspection, conducted at approximately 10:45am on June 17, 2025, there were open dishwasher cleaning agents sitting on an open metal shelf in the kitchen. The shelf sits close to the ground creating a possible poison hazard. Additionally, there were various cleaning agents located on the shelves of a closet, which was unable to be locked or latched.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/17/2025 all cleaning agents were removed from cited locations and placed in a locked closet.
On 6/18/2025 faulty and/or defective locks were replaced to secure hazardous materials.
Effective immediately, Assistant Director or designee will conduct daily facility inspections for potential hazards and/or safety concerns.
Director will train all staff on hazard recognition, immediate corrective actions, and reporting protocols by 9/1/2025. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a release of information form in one of eight applicable client records reviewed.
Client #10 was admitted on July 18, 2024 and was discharged on November 11, 2024. A release of information form to an external individual was signed and dated by the client on July 18, 2024; however, there was no purpose of the disclosure included on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Upon hire, staff will be trained in how to properly complete consents and/or release of information for all individuals the program will disclose information to during the client's treatment process.
The Director or designee will conduct monthly chart audits to ensure compliance is being maintained and documents are properly completed.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent form was offered to the client in two of eight applicable client records reviewed.
Client #4 was admitted on August 20, 2024 and was discharged on June 7, 2025. There was a release of information form to a housing agency signed and dated by the client on March 19, 2025; however, there was no documentation in the record indicating the release form was offered to the client.
Client #10 was admitted on July 18, 2024 and was discharged on November 11, 2024. There were release of information forms to an outside individual and a government agency signed and dated by the client on July 18, 2024; however, there was no documentation in either record indicating the release forms were offered to the client. Additionally, a release of information form to another treatment provider was signed and dated by the client August 23, 2024; however, there was no documentation in the record indicating the release form was offered to the client.
This is a repeat citation from the May 29, 2024 and July 29, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, upon hire staff will be trained to properly complete consent forms and offer the participant a copy of the completed consent. Staff will be trained to have client initial whether to accept or decline a copy of their consents and/or ROI.
Effective immediately, Assistant Director will review admission paperwork and will ensure accuracy and completeness is maintained.
Director or desginee will conduct monthly chart audits for compliance and ensure that the consents/ROIs properly reflect that the participant was offered a copy of the form. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire, or ambulance personnel.
There was documentation indicating the police, fire, or ambulance being reported at the facility on June 21, 2024, September 18, 2024, and June 2, 2025. However, there was no documentation indicating any of the incidents were reported to the Department as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, upon hire, staff will be trained in incident reporting, documentation, and submission expectations and timeframes.
Program Director or designee will conduct daily "real time" incident reviews to ensure that reports are submitted in the portal on time.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a physical examination in three of eight applicable client records reviewed.
Client #2 was admitted on March 10, 2025 and was active at the time of the inspection. There was no documentation in the record of a physical examination being completed at the time of the inspection.
Client #4 was admitted on August 20, 2024 and was discharged on June 7, 2025. There was no documentation in the record of a physical examination being completed at the time of the inspection.
Client #10 was admitted on July 18, 2024 and was discharged on November 11, 2024. There was no documentation in the record of a physical examination being completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately upon hire, staff will be trained to properly schedule and transport newly admitted clients for mandatory medical (i.e. physical examinations) appointments and the timelines.
Director or designee will facilitate daily staff meetings to discuss scheduled appointments (i.e. medical, dental, specialist, to include follow-up) and remove barriers which will prohibit client from attending any/all scheduled appointments.
Director will conduct weekly appointment reviews to ensure appointments are properly completed in a timely manner. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in one of one applicable client records reviewed.
Client #5 was admitted on September 26, 2024 and was discharged on April 24, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately and upon hire, staff will be trained in documentation and expectation for discharge/after care follow-up.
Director or designee will conduct monthly chart audits to ensure updates are completed on time and compliance is being maintained. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete unannounced fire drills at least once a month was submitted and approved by the Department for the July 28, 2023 and May 29, 2024 annual licensing inspections. Failing to complete unannounced fire drills at least once a month was again found to be a deficiency in the June 16, 2025 through June 17, 2025 annual licensing inspection.
A plan of correction for failing to ensure a copy of a consent form was offered to the client was submitted and approved by the Department for the July 28, 2023 and May 29, 2024 annual licensing inspections. Failing to ensure a copy of a consent form was offered to the client was again found to be a deficiency in the June 16, 2025 through June 17, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effectively immediately, Program Director or designee will facilitate follow-up meeting with staff to discuss inspection deficiencies.
Effective immediately, Director or designee will provide training and monthly chart audits for all newly hired and current staff on clinical documentation protocol (i.e. consents, release of information, required medical appointments, incident reporting and submission and discharge and aftercare follow up).
Effective immediately, Director or designee will provide training on OSHA safety protocols, identifying hazardous materials, safety concerns, and reporting/documenting on newly created Playground Safety Checklist.
Effective immediately, Director or designee will ensure all fire drills remain unannounced and scheduled for varying days/shifts/and times. Director will conduct monthly fire drill log audits to ensure compliance is maintained. |