INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services Inc 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 the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that 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 Department approved curriculum in two out of four applicable files reveiwed. 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. Employee #9 was hired as a Youth Care Staff on March 7, 2023. His TB/STD training was due no later than March 7, 2025; however, none was completed. Employee #10 was hired as a Youth Care Worker on June 20, 2023. His training was due no later than June 20, 2025; however, his HIV/AIDS and TB/STD training was not completed as of the time of the inspection. These findings were reviewed with the facility staff during the licensing process. This is a repeat citation from the September 11, 2024 licensing inspection.
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Plan of Correction
These trainings will be completed through the DDAP on-demand training system. Employee #9 will complete the TB/STD training before the deadline of October 31, 2025.
Employee #10 will complete the TB/STD and HIV/AIDS trainings before the deadline of October 31, 2025.
All new DARS, Inc employees hired after this POC will complete the training within the prescribed time frames by utilizing the on-demand training system.
Adherence to this plan will be monitored by the immediate supervisor of the identified staff members. The Operations Manager will oversee the supervisors to ensure compliance. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and the residential facility are unobstructed. The exit from the library and exit into the chapel hallway were obstructed.This finding was reviewed with the facility staff during the licensing inspection process.
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Plan of Correction
Obstructions to exits were removed at the conclusion of the facility inspection.
The identified areas were obstructed by objects placed by separate organizations that lease space in parts of the facility buildings. The tenants were informed that nothing is permitted to be placed in any area that would obstruct any exit doors.
Adherence to this requirement will be maintained by the Maintenance Supervisor during weekly facility walkthroughs. |