INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 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 two of the fifteen staff are trained in CPR and three are trained in 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.
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Plan of Correction
704.11c2 The Facility Director will meet with Clinical Director(s) and Human Resources to review 704.11c2 standard and revise tracking of CPR/First Aid compliance. The Facility Director and Human Resources will review monitoring system and review 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 standard. Compliance with this standard will be enforced and monitored by Facility Director and Human Resources Department through compliance reviews. |