INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26, 2026 through August 27, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, 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(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure each individual training plan was based upon the employee's previous education, experience, current job functions, and job performance in three of nineteen applicable personnel records reviewed.
Employee # 3 was hired as a clinical supervisor on February 10, 2021. The individual training plan, completed on December 8, 2025, was not based on the employee's previous education, experience, current job functions and performance as it was identical to the training plans for a lead counselor and a counselor.
Employee # 5 was hired as a lead counselor on March 21, 2023. The individual training plan, completed on December 3, 2025, was not based on the employee's previous education, experience, current job functions and performance as it was identical to the training plans for a clinical supervisor and a counselor.
Employee # 13 was hired as a counselor on March 14, 2025. The individual training plan, completed on January 4, 2026, was not based on the employee's previous education, experience, current job functions and performance as it was identical to the training plans for a clinical supervisor and a lead counselor
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All employee training plans are being modified. The Director of Quality/Compliance and Performance Improvement will now be responsible for finding training that reflects and addresses an employee's previous education, experience, current job and job performance. A team of three was assembled and met on 9/3/26 to begin reviewing the learning platform and comparing those trainings to the training requirements from DDAP. The goal is to have all of training needs mapped out for all employees (new hire & current) by the end of October. Where necessary, training will be completed outside of the learning platform. The team will start modifying the training plans in the learning platform on November 3. All Training Plans should be in full compliance by 12/23/26. |
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 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.
At the time of the inspection, conducted on August 27, 2026 at approximately 11:30 a.m., there was a window in the second-floor detox lounge that was broken and had a spiderweb-pattern fracture throughout.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A business that makes and installs windows has been contracted by Self Help Movement, Inc. to replace the broken window. The Maintenance Manager is in contact with the manager at the business and is responsible for making sure the window is replaced. The window is to be replaced by 9/25/2026.
Because windows have been broken multiple times by someone who it is believed is shooting at the windows with a high powered bebe gun, the cameras are being checked and more closely monitored to try to catch the shooter and have them prosecuted. In the meantime, the windows will be replaced as they are broken. |
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 cold food at or below 40 degrees Fahrenheit, hot food at or above 140 degrees Fahrenheit, and frozen food at or below 0 degrees Fahrenheit.
At the time of the inspection, conducted on August 27, 2026 at approximately 10:30 a.m., the temperature inside the ice cream freezer was measured at 5 degrees Fahrenheit.
This is a repeat citation from the September 4, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The freezer is old and does not hold the temperature as required. It will be replaced. The Director of Food Services is currently pricing freezers. The cost will be submitted to the CFO for approval, and the freezer is to be replaced by 10/31/2026. The Director of Food Services will be responsible for monitoring the temperature of the freezer to make sure the required temperatures are maintained. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 12 was admitted to the inpatient non-hospital activity on January 14, 2026 and was discharged against medical advice on April 8, 2026. There was no documentation in the record indicating the emergency contact was notified of the client's discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be re-educated about the agency's policy to contact the client's emergency contact within 12 hours when the client leaves the facility against medical advice (AMA). The Clinical Supervisor will be responsible for checking all AMA discharges and following up with staff as needed to ensure emergency contacts are contacted within 12 hours of the client leaving the facility. We will be in full compliance by 9/18/2026. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of fourteen client records reviewed.
Client # 11 was admitted to the inpatient non-hospital activity December 8, 2025 and was discharged on January 29, 2026. There was documentation of a follow-up family session with the client and two family members occurring on January 30, 2026; however, there was no consent to release information forms signed by the client documented in the record prior to the disclosures of information.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide re-education about the need for written consent. Staff will be reminded that verbal consent is not sufficient for contact with anyone other than the client themselves. A single consent allowing sharing of information with a coordinated team, integrated medical providers, or support networks for the purpose of treatment, payment, and healthcare operations has been implemented. The Clinical Supervisor will ensure charts are audited after intake for compliance with the consents to release information. We will be in compliance by 9/18/2026. |
709.63(a)(2) LICENSURE D & A support plan
709.63. 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:
(2) Drug and alcohol support plan.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include documentation of a drug and alcohol support plan, in two of six applicable client records reviewed.
The facility policy and procedure manual stated that the drug and alcohol support plan/preliminary treatment plan will be completed within 24 hours of admission and will cover the first seven days of treatment.
Client # 2 was admitted to the inpatient non-hospital detoxification activity on August 20, 2026 and was still active at the time of the inspection. The drug and alcohol support plan was due to be completed by August 21, 2026; however, the plan was not completed until August 26, 2026.
Client # 3 was admitted to the inpatient non-hospital detoxification activity on August 23, 2026 and was still active at the time of the inspection. The drug and alcohol support plan was due to be completed by August 24, 2026; however, the plan was not completed until August 25, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The preliminary support/treatment plan will no longer be the responsibility of the admission staff who are not scheduled to work weekends. The plans will now be the responsibility of the counselors who already see the clients within 24 hours of admission. Nursing is also completing a Recovery Care Plan within 24 hours of admission. The counselors and nurses have all been educated about the expectation. The charts will be monitored for compliance by the Clinical Supervisor on a weekly basis and the Director of Quality/Compliance and Performance Improvement using random spot checks once or twice weekly. We are expected to be in compliance by 9/30/2026. |