INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Highland House, 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(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 administrative information, the facility failed to document an assessment of staff training needs for the January 2026-December 2026 training year.
The facility ' s policy states that this will be completed by January 31 of each year. This was not completed at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the May 21-22, 2025 annual licensing inspection.
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Plan of Correction
All staff will be provided with an annual assessment of trainings of training needs that is individualized and signed off by the staff member and the Acting Executive Director. Based on the revised policy dated October 6, 2025, all employees will submit this form to their supervisor no later than January 15th of each year.
Supervisors are responsible for reviewing the submitted forms to the Human Resource Specialist by January 31st of each year. The Human Resource Specialist is responsible for ensuring they are all submitted timely.
Per the policy, the Human Resource Specialist will create an overall written plan for addressing all staff training needs by February 15th of each year.
The Human Resource Specialist will create Outlook reminders to ensure this occurs timely.
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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 administrative information, the facility failed to document an overall plan to address staff training needs for the January 2026-December 2026 training year.
The facility ' s policy states that this will be completed by February 15 of each year. This was not 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
The facility completed a fiscal year overall plan for the staff training needs instead of a calendar year plan. Moving forward a calendar year plan will be completed by the Human Resource Specialist by February 15th of each year. The HR Specialist will add outlook reminders to her calendar to ensure timely completion. |
704.11(a)(4) LICENSURE Evaluation of Overall 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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative information, the facility failed to document an annual evaluation of the overall training plan for the January 2025-December 2025 training year.
The facility ' s policy states that this will be completed by January 31 of each year. This was not completed at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the May 21-22, 2025 annual licensing inspection.
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Plan of Correction
The Human Resource Specialist will complete an annual review of the prior calendar year overall training plan by January 31st of the following year. The HR Specialist will set Outlook reminders to ensure timely completion.
These are new responsibilities for the HR Specialist and she will ensure compliance. |
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 the facility's fire drill log for the months of May 2025 through April 2026, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was no overnight fire drills documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will complete an annual plan to include fire drills that are conducted during sleeping hours at a minimum of at least every six months. The plan will be due to the Executive Director no later than December 31st for the upcoming calendar year. For the remainder of 2026, the Clinical Director will submit a modified plan to the Executive Director no later than June 30, 2026. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of the facility annual report, the governing body failed to make available an annual report for 2025 to include a statement disclosing the names of officers, directors and principal shareholders.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will complete an annual facility report at the end of each fiscal year (July - June) to be completed by August 15th after the fiscal year ends.
Outlook reminders will be set to ensure compliance. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with the director, the project failed to document an annual financial audit for the fiscal years ending June 30, 2023 and June 30, 2024.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the May 21-22, 2025 annual licensing inspection.
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Plan of Correction
The financial audit for FY 22/23 is currently in draft status review. This delay was due to difficulty in finding required documents after previous director retired.
The financial audit for FY 23/24 is currently being completed and anticipated to be completed and in draft status by June 30, 2026.
Ongoing, the Highland House audit will be completed in tandem with the Lawrence County SCA audit as they are now merged. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluations that were reviewed and signed by the employee in one of two applicable records.
According to the facilities policy and procedure, annual performance evaluations are to be completed with supervisor and employee annually.
Staff #3 was hired as a counselor on May 6, 2024 and still employed. The annual performance evaluation was completed on May 6, 2025; however, there was no documentation that it was reviewed and signed by the employee.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 21-22, 2025 annual licensing inspection.
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Plan of Correction
All Highland House staff will be entered into the Human Resource Management System (HRMS) by the Executive Director & the Human Resource Specialist no later than September 30, 2026, so that the 2026 performance evaluations can be completed electronically. The Human Resource Specialist will ensure that all 2026 performance evaluations are completed electronically and signed by the staff member and the supervisor and saved accordingly in HRMS. |
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 a review of applicable client records, the facility failed to report the department within three business days an unusual incident involving an event at the facility requiring the presence of police, fire, or ambulance personnel in one of one records.
Client #1 was admitted on August 19, 2025 and discharged on October 24, 2025. Interview with facility staff and a case note in the client record indicated that the police were present at the facility on the client ' s discharge date; however, this was not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will review the policy regarding reporting of unusual incidents by June 4, 2026; to ensure compliance of all situations that need to be reported.
Effective June 4, 2026, all reportable incidents will be reported, as required. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in one of three client records. The policy and procedure indicates follow-up contact must be made at thirty days, six months, and one year after discharge.
Client #4 was admitted on September 30, 2025 and was discharged on March 31, 2026. The thirty-day follow-up contact was due to be completed no later than May 1, 2026; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the May 21-22, 2025 annual licensing inspection.
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Plan of Correction
The Clinical Director will ensure the Case Manager completes all follow ups within the 30 days. The Case Manager will put reminders into outlook or a calendar to ensure these are completed as required. The Clinical Director will review bi-weekly to ensure all follow ups have been completed and documented in the electronic health record.
Management will also be including this on a general house admission and discharge spreadsheet to ensure this occurs timely. |