INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on August 21, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Valley View Health Services 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 records, the facility failed to complete an assessment of staff training needs within the time frame listed in the facility policy and procedures.
The facility policy and procedure states an assessment of staff training needs will be completed by January 15 of each year. The assessment of staff training needs for the 2025 training year was not completed until June 1, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The audit showed that our staff assessment of training needs were not completed by the time mandated.
Our Policy Manuel at Valley View Health Services state that an assessment of the training needs will be completed by the 15th of January, annually.
Moving forward, the Project Director will complete an assessment of staff development needs by Jan 15th, moving forward.
To ensure this is being completed, Valley View Health Services, has added this as an item for our January monthly business meeting.
These changes have already been noted in our Valley View Health Services P&P manual and our now made standard in our January business meeting. These changes will be implemented by 9/22-2025 |
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 records, the facility failed to complete an overall plan for addressing training needs within the time frame listed in the facility policy and procedures.
The facility policy and procedure states an overall plan for addressing training needs will be completed by January 30 of each year. The overall plan for addressing training needs for the 2025 training year was not completed until June 1, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The audit demonstrated that we at Valley View Health Services failed to complete a plan for addressing training needs by the necessary date.
Moving forward the project director will address this by ensuring that the training plan is implemented and reviewed with all therapists by January 15th of each year. At this time training needs will also be addressed and reviewed for the calendar year.
To ensure that this is being implemented at Valley View this will be added into our annual staff meeting during the beginning of January annually (before the 15th of the month). |
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 administrative records, the facility failed to maintain a written fire drill record for the months of January 2025 through August 2025 that included the time it took for evacuation, problems encountered, and whether the smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 20, 2024 annual licensure inspection.
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Plan of Correction
The audit demonstrated that at Valley View Health Services we did not include on our 2025 fire log, some pertinent information
Moving forward the project director has made the necessary corrections to our fire safety log. The log now includes a place to record time of evacuations, and whether the smoke detectors are operative or not. We have added to our log a space with categories to reflect the time it took to evacuate, the problems encountered and a place to record if the smoke detectors were checked or not for each month.
The new fire logs will be recorded monthly as these checks are performed and the project director will ensure that our documentation correctly reflects these changes / and that these changes are consistently recorded. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The fire drill log indicated the smoke detector was not set off for fire drills on the following dates: January 1, 2025; February 15, 2025; March 19, 2025; April 12, 2025; May 7, 2025; June 16, 2025; July 25, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Audit showed that our fire drill log did not record if the smoke detectors were set off and consistently checked with each fire drill.
Valley View Health Services has made corrections to our fire drill policy and to our fire drill log. Moving forward the project director will ensure that we are not only testing the smoke detectors but also recording this information. The project director will ensure that the alarms are being set off at the time of the drill, ensuring that they are in working order. IF they are not in working order the project director will ensure that the necessary corrections are made at that time.
In addition the project director will also ensure that we perform a monthly review at the time of the fire drills to ensure that we are following proper protocol and that this is being recorded correctly. A new space was added to our fire drill log to allow us to record that these smoke detectors were set off and functional. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a review of the physical plant, the facility failed to ensure the hours of operation were displayed conspicuously to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The audit showed that we did not dispay a sign that clearly showed our hours of operation to the general public.
Valley View Health Services will post a sign that displays hours of operation. A sign has been purchased. The project director will ensure that we will be posting this sign at the entrance.
The project director will ensure that this sign is in place and visible to the general public revealing Valley View Health Services operating hours to the general public. This will be completed by 9/30-2025.
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