INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development 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 personnel records, the project failed to ensure that staff persons and volunteers received 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 in four of seven records reviewed.
Employee # 4 was hired as a counselor on March 31, 2025, and was currently in that position at the time of the inspection. Employee #4 was due to have the communicable disease trainings no later than March 31, 2026. There was no documentation that the employee received the six hours of HIV/AIDS training and the four hours of TB/STD training as of the date of the inspection.
Employee # 5 was hired as a direct support staff member on January 30, 2023 and was currently in that position at the time of the inspection. Employee #5 was due to have the communicable disease training no later than January 30, 2025. There was no documentation that the employee received the six hours of HIV/AIDS training and the four hours of TB/STD training as of the date of the inspection.
Employee # 6 was hired as a direct support staff member on December 23, 2023 and was currently in that position at the time of the inspection. Employee #6 was due to have the communicable disease training no later than December 23, 2025. There was no documentation that the employee received the four hours of TB/STD training as of the date of the inspection.
Employee # 7 was hired as a behavioral health technician on March 21, 2024 and was currently in that position at the time of the inspection. Employee #7 was due to have the communicable disease training no later than March 21, 2025. There was no documentation that the employee received the six hours of HIV/AIDS training and the four hours of TB/STD training as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By 08/15/2026, Assistant Director will complete individual supervision to ensure employees attend a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics training using a Department approved curriculum.
Of the four staff identified, one has registered for the two outstanding trainings scheduled for 08/24/26. Three additional staff members are in the process of trying to regain access to their DDAP portals. They have until 08/10/26 to register for the 08/24/26 training.
Director will monitor for ongoing compliance through employee training file. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the project failed to ensure that one clinical supervisor completed 12 clock-hours of training annually.
Employee #3 was hired as a clinical supervisor on February 6, 2024, and was currently in that position at the time of the inspection. Employee #3 only completed 8.5 clock-hours of training for the July 2024 through June 2025 training year.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By 07/30/2026, Director will meet with Clinical Manager to complete Individual Training Plan. The Individual Training Plan will reflect the required 12 hours of training to be completed annually. Director and Clinical Manager will review training file to ensure training hours are complete. Director will also monitor through ongoing supervision. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of fire drill logs from July 2025 through May 2026, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/31/2026, Assistant Director will train and educate Direct Support Professional to ensure a fire drill is conducted during sleeping hours at least every 6 months. Director will monitor for compliance. |
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 a review of client records, the project failed to follow their written procedures to contact an emergency contact within 12 hours of a client leaving the facility Against Staff Advice (ASA) in one of two applicable records reviewed.
Client #4 was admitted to the inpatient non-hospital level of care on September 22, 2025, and was discharged Against Staff Advice (ASA) on December 19, 2025. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By 08/30/2026, Program Director and Clinical Manager will train all staff on the completion of the Emergency Contact Form which is to be completed within 12 hours of a client leaving the facility Against Staff Advice. This training will become a part of staff onboarding to prevent reoccurence. The Clinical Manager will ensure that the form is completed at each Against Staff Advice. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the project ' s policies and procedures, the project failed to document a psychosocial evaluation within two weeks of the admission date, per the project ' s policy, in four out of seven records reviewed.
Client #1 was admitted to the inpatient non-hospital level of care on December 22, 2025, and was active at the time of the inspection. A biopsychosocial evaluation was not documented in the client record.
Client #4 was admitted to the inpatient non-hospital level of care on September 22, 2025, and was discharged on December 19, 2025. A biopsychosocial evaluation was not documented in the client record.
Client #5 was admitted to the inpatient non-hospital level of care on December 5, 2025, and was discharged on March 6, 2026. A biopsychosocial evaluation was not documented in the client record.
Client #6 was admitted to the inpatient non-hospital level of care on December 16, 2025, and was discharged on May 18, 2026. A biopsychosocial evaluation was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By 08/30/2026, Program Director will meet with the clinical Manager and therapist to review the requirements of documenting a psychosocial evaluation within two weeks of hte admission date. Program Director will monitor for compliance through chart reviews and individual supervision. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the project failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of the seven records reviewed.
Client #3 was admitted on February 16, 2026, and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 5, 2026; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
Client #5 was admitted on December 5, 2025 and was discharged on March 6, 2026. The individual treatment and rehabilitation plan was completed on December 22, 2025; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
Client #7 was admitted on January 21, 2026 and was discharged on February 12, 2026. The individual treatment and rehabilitation plan was completed on February 9, 2026; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By 08/10/2026, Director will provide supervision to the Clinical Manager and therapist regarding documenting the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. Director will monitor ongoing compliance through chart reviews. |