INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family and Community Ministries 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that at least one person trained in CPR and first aid is onsite during project's working hours.
Only one of the five staff are trained in CPR and first aid which does not allow for at least one person onsite during project's working hours.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 7, 2025 licensing inspection.
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Plan of Correction
704.11c2 The Facility Director will meet with Clinical Director(s), team leaders and human resources to review 704.11c2 standard and revise tracking of CPR/first aid training compliance. The Facility Director and human resources will monitoring system and staff completion on a quarterly basis. Human resources will send an email reminder to staff and Facility director 3 months prior to the expiration of their CPR/First aid training. Current staff that are not certified or have expired certifications will complete CPR/First aid training by 7/31/2026 and provide a copy of certificate to facility director and human resources on or before 7/31/2026. Facility director will use weekly staff meetings for review and compliance of this standard. Compliance with this standard will be enforced and monitored by facility director and HR department through compliance reviews. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from June, 2025 through May, 2026, the facility failed to maintain a written fire drill record including the amount of time it took to evacuate on January, 2026 drill log and the exit route used on December, 2025 drill log.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.28d4 The facility director will meet with clinical directors, clinical staff and administrative staff to review 705.28d4 and educate all staff of regulation. Clinical and/or administrative staff will submit monthly fire logs to facility director for review of accuracy of written report. This will be in compliance effective 7/1/2026. Compliance with this standard will be enforced and monitored by facility director through monthly fire drill log reviews, staff meetings and ongoing staff training. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven applicable records reviewed.
Client #3 was admitted on October 20, 2025 and was discharged on January 6, 2026. The treatment plan dated October 20, 2025 indicated one time per week of individual sessions. There was no documentation of the client receiving individual therapy between October 20, 2025 and January 6, 2026.
Client #4 was admitted on January 28, 2026 and discharged on March 26, 2026. The treatment plan dated January 28, 2026 indicated weekly individual sessions. The only individual sessions were February 18, 2026 and March 4, 2026.
Client #6 was admitted on October 20, 2025 and discharged on January 22, 2026. The treatment plan dated October 20, 2025 indicated individual sessions every other week. There was no documentation that the client received individual therapy between November 13, 2025 and December 17, 2025 and between December 19, 2025 and January 14, 2025. It shows a session on December 18, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92c The facility director will meet with clinical staff to review 709.92c and provide education to ensuring counseling services are provided in accordance with the treatment plan. Facility director will use weekly staff meetings to re-educate clinical staff of meeting counseling service provisions and documenting accordingly in the ECR. Facility director will conduct quarterly record reviews of charts for compliance. This will be in compliance effective 7/1/2026. Compliance with this standard will be enforced and monitored by facility director through staff meetings, staff trainings, quarterly reviews and supervision. |