INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2025 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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed the mandatory 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in three of three applicable personnel records reviewed.
Employee #6 was hired as direct support staff on January 27, 2023. The HIV/AIDS training and TB/STD and other health topics training were due to be completed no later than January 27, 2025. There was no documentation in the record that either training was completed as of the date of the inspection.
Employee #7 was hired as direct support staff on January 30, 2023. The HIV/AIDS training and TB/STD and other health topics training were due to be completed no later than January 30, 2025. There was no documentation in the record that either training was completed as of the date of the inspection.
Employee #8 was hired as direct support staff on December 13, 2021. The TB/STD and other health topics training was due to be completed no later than December 13, 2023. There was no documentation in the record that the training was completed as of the date of the inspection.
This is a repeat citation from the April 23, 2024 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Director will ensure all staff are provided with the name and location sites for mandatory trainings.
Effective immediately, Director will ensure all direct manager's are provided with monthly documentation informing identifying their direct reports and required trainings.
Effective immediately, Director or designee will work to remove all barriers to mandatory to include but not limited to: work conflicts and/or payment for trainings.
Effective immediately, Director will conduct monthly audits to ensure staff are maintaining compliance with trainings.
Effective immediately, manager's will meet with director monthly to discuss non-compliance and barriers which prohibit their direct reports to acquire required training.
Effective immediately, Director or designee will ensure that all new hires are provided with a copy of all mandatory trainings during on-boarding and will assist with registering for those training immediately.
Employees#6, #7, and #8 are expected to have the mandatory trainings completed by December 31, 2025. |
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 administrative documentation, the facility failed to ensure there were a sufficient number of staff persons certified in CPR and trained in first aid, so that at least one person trained in these skills was onsite during the project's hours of operation.
The hours of operation are 24 hours per day, 7 days per week, as this is a residential facility. Facility staff were unable to provide documentation of CPR certification and first aid training for the two employees listed on the work schedule during the May 10, 2025, 11pm to 7am shift. This led to no CPR-certified and first aid trained employees being present onsite from 11pm to 12am.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately, Program Director or designee will complete the on-boarding of new hires and current staff that includes registering for CPR/FA in a timely manner.
Effective immediately, Program Director will review all staff files monthly to ensure required/mandatory trainings are completed in a timely manner.
Effective immediately, Program Director or designee will ensure to remove potential barriers to training.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to ensure each bathroom was provided with a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer.
At the time of the physical plant inspection, which was conducted between 1:30pm and 2:00pm, the first-floor bathroom and the three second-floor bathrooms did not have any individual paper towels or a mechanical dryer.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Paper towels were immediately placed inside all bathrooms on 6/25/2025.
Staff will check as part of their facility rounds to ensure all bathrooms are adequately equipped with paper towels at all times and will notify management when supplies are low for more to be ordered. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the April 2024 through May 2025 fire drill logs, the facility failed to identify the time of the fire drill and if the fire alarm or smoke detector was operative on all of the written fire drill record logs.
The logs for the fire drills conducted on December 12, 2024, February 25, 2025, and May 23, 2025 did not include documentation of the time of the drills. Additionally, the log for the fire drill conducted on March 17, 2025 did not include documentation of whether fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Assistant Director will review all fire drills logs submitted by staff for accuracy and completion before submitting to be filed.
Assistant Director will ensure to include on the log whether or not the fire alarm and/or smoke detector was activated during the fire drill.
Director will review monthly logs to ensure they are in 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 the policy and procedure manual and a 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's policy and procedure manual stated the program will contact the participant's emergency contact when the participant leaves against facility advice.
Client #5 was admitted on July 11, 2024 and was discharged against facility advice on September 26, 2024. There was no attempted emergency contact notification documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #5 EC was contacted, however staff failed to document.
Director will follow-up with Assistant Director and Clinical Manager to ensure communication is documented for all outreach made to emergency contacts for facility residents. |
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 the review of personnel records, the facility failed to ensure the completion of annual, written individual staff performance evaluations, which shall be reviewed and signed by the employee, in one of one applicable personnel records reviewed.
Employee # 2 was hired as the facility director on June 27, 2022 and was still employed in the position. There was no individual performance evaluation, for the 2024 year, documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Director will meet with immediate supervisor to discuss annual evaluation and complete by 8/30/2025.
Effective immediately, Director will meet with immediate supervisor monthly and/or quarterly to discuss evaluation goals and tasks.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of five applicable client records reviewed.
Client # 5 was admitted on July 11, 2024 and was discharged on September 26, 2024. The individual treatment plan was completed on August 2, 2024 and the first update was due no later than September 2, 2024; however, the update was not completed until September 10, 2024.
Client # 6 was admitted on November 19, 2024 and was discharged on May 19, 2025. A treatment plan update was completed on March 18, 2025 and the next update was due no later than April 18, 2025; however, the update was not completed until May 16, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Manager will perform chart audits to ensure clinical programmatic timelines are adhered to.
Director will conduct random chart audits to ensure compliance is maintained. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in one of two applicable client records reviewed.
Client #1 was admitted on March 5, 2025 and was active at the time of inspection. There were no case consultation notes documented in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Case Consultations will be held within the first 90 days of treatment with full treatment team and documented in the client's chart.
Effective immediately and upon hire, staff will be trained in clinical documentation and expectations by Clinical Manager.
Effective immediately, Clinical Manager will inform staff and resident of up-coming case consultation meeting.
Effective immediately, Clinical Manager will conduct monthly chart audits to ensure compliance is being maintained.
Effective immediately, Program Director will conduct random chart audits for compliance.
Client #1 case consultation was facilitated and documented by Clinical Manager on 7/1/2025.
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