INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Steel Wellness Center LLC 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of administrative records and staff interview, the facility failed to ensure a written individual training plan for each employee was developed in five of five applicable records.
Facility policy and procedure states that each year in June drug and alcohol employees will complete an individualized training plan for the coming fiscal year.
Staff #1 was hired to the position of Project Director on December 9, 2025 and was in this position at the time of review. Staff #1 had an individual training plan completed on January 1, 2026. However, staff #1 did not have an individual training plan developed in June 2026.
Staff #2 was hired to the position of Clinical Supervisor on December 9, 2025 and was in this position at the time of review. Staff #2 had an individual training plan completed on January 1, 2026. However, staff #2 did not have an individual training plan developed in June 2026.
Staff #3 was hired to the position of counselor on March 9, 2026 and was in this position at the time of review. Staff #3 had an individual training plan completed on February 1, 2026. However, staff #7 did not have an individual training plan developed in June 2026.
Staff #4 was hired to the position of counselor on January 5, 2026 and was in this position at the time of review. Staff #4 had an individual training plan completed on February 1, 2026. However, staff #4 did not have an individual training plan developed in June 2026
Staff #5 was hired to the position of case manager on December 9, 2025 and was in this position at the time of review. Staff #5 had an individual training plan completed on January 1, 2026. However, staff #5 did not have an individual training plan developed in June 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Steel Wellness Center acknowledges the finding regarding the failure to develop updated written Individual Training Plans for applicable employees during the required annual review period in June 2026.
Upon review of the deficiency, facility leadership identified that Individual Training Plans had been completed for staff following hire; however, the plans were not subsequently updated during the facility's established annual June review period as required by facility policy and DDAP requirements.
As corrective action, Human Resources was educated on the requirements for the development, maintenance, and annual review of Individual Training Plans for all applicable drug and alcohol program employees. Human Resources was specifically instructed that completion of a training plan upon hire does not replace the requirement to review and develop an updated Individual Training Plan during the established annual review period.
By August 31, 2026, all applicable Steel Wellness Center staff will have a new and current Individual Training Plan completed and maintained within their personnel file.
Moving forward, Individual Training Plans will be reviewed and updated annually each June, with the next annual review occurring in June 2027. Plans will also be updated as needed when changes in an employee's position, responsibilities, performance, or identified training needs warrant modification. Human Resources will be responsible for monitoring completion and maintaining documentation within each applicable employee's personnel file to ensure ongoing compliance and prevent recurrence. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log and staff interview, the facility failed to conduct fire drills at least once a month.
The fire drill log was reviewed from January 2026 through July 2026. No fire drill was completed for July 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility reviewed the cited requirement and identified that a fire drill was not conducted during July 2026. Facility leadership reviewed the requirement that fire drills be conducted at least once each month and reinforced the expectation for timely completion and documentation.
As of August 2026, the facility has corrected the deficiency and completed the required August fire drill. Moving forward, fire drills will be conducted and documented at least once each month in accordance with regulatory requirements.
The Clinical Director will be responsible for overseeing and ensuring completion of a fire drill each month. Fire drill completion will be tracked monthly to prevent any missed drills.
Compliance will conduct a monthly review of the facility's fire drill records to verify that the required drill was completed and appropriately documented for that month. Any missed or incomplete documentation will be immediately communicated to the Clinical Director for corrective action and follow-up to ensure ongoing compliance. |
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 the facility fire drill log, the facility failed to ensure to maintain a written fire drill record that includes problems encountered.
Fire drill logs were reviewed from January 2026 through July 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility reviewed the cited requirement and identified that previous fire drill documentation did not consistently include documentation of any problems encountered during the drill, including documentation when no problems were identified.
As of August 2026, the facility has corrected this deficiency. A fire drill was completed for August 2026, and the fire drill documentation now includes a designated area to document any problems encountered during the drill or to indicate that no problems were encountered.
The facility will conduct and document a fire drill monthly. Each fire drill record will include all required information, including the date and time of the drill, participants, evacuation information, method of initiating the drill, and any problems encountered.
The Clinical Director will oversee completion and documentation of the monthly fire drills and ensure that the fire drill record is completed in its entirety.
Compliance will review the fire drill documentation monthly to verify that a drill was conducted for the month and that all required elements, including problems encountered or documentation that no problems occurred, are present. Any identified deficiency will be addressed immediately with the Clinical Director and responsible staff to ensure ongoing compliance. |
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 facility fire drill log and staff interview, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Fire drill logs were reviewed from January 2026 through July 2026.
The facility fire drill log indicated fire drills were conducted in January 2026, February 2026, March 2026, April 2026, May 2026, and June 2026. For January 2026, February 2026, and March 2026 the fire drill log indicates that the fire alarm was not activated, and how the drill was announced is described as " Staff met with CD in her office who announced fire drill " .
For April 2026, May 2026, and June 2026 the fire drill log indicates that the fire alarm was not activated, and how the drill was announced is described as " Announcement to staff " .
Staff interview confirmed that no fire alarm or smoke detector was set off during these fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility reviewed the cited deficiency and revised its fire drill process to ensure that all required fire drills are conducted consistently and include a clearly identifiable method for initiating the drill. Effective 8/31/2026, the facility will conduct fire drills at least monthly. At the start of each drill, staff will make a clear verbal announcement throughout the facility that a fire drill is beginning and will immediately initiate the facility's established evacuation procedures. Staff will direct all clients and personnel to evacuate using the designated emergency exits and proceed to the identified assembly area.
Each fire drill will be documented on the facility's fire drill log, including the date and time of the drill, method used to initiate/announce the drill, evacuation time, staff and client participation, evacuation procedures followed, and any problems encountered. Any identified concerns will be reviewed by facility leadership and corrective action will be taken as necessary.
The facility operates within a mixed-use, multi-tenant building and does not have independent control over the building-wide fire alarm system. Property management does not permit the facility to activate the building-wide fire alarm on a monthly basis because activation impacts and disrupts all tenants and businesses within the building. The facility coordinates with property management regarding overall fire and life-safety requirements, and the building undergoes annual fire alarm and fire safety inspection/testing in coordination with the local fire department. Documentation of the building's annual inspection/testing will be maintained by the facility as part of its fire and life-safety records.
Due to the facility's location within a mixed-use building and the restrictions imposed by property management regarding monthly activation of the building-wide fire alarm, the facility submitted a formal exception request to DDAP on 8/26/2026. The exception request is being pursued separately and is not being utilized as the basis for this Plan of Correction.
The Clinical Director will be responsible for ensuring that monthly fire drills are completed and appropriately documented. Compliance will review the fire drill documentation monthly to verify that drills are conducted as required, appropriately announced and initiated, and include all required documentation. This revised fire drill process was implemented effective 8/31/2026.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent shall be offered to the client in three of three records.
All three records reviewed contained client consents, however clients were not offered a copy of the client consent. This was confirmed by facility staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility identified that the option for clients to accept or decline a copy was included on the facility's general consent forms; however, this language was not included on the Release of Information (ROI) forms. The facility corrected this deficiency on August 13, 2026, by updating the ROI process to document that each client is offered a copy and may indicate whether they accept or decline the copy.
As of August 13, 2026, all current client records have been updated to reflect that clients were offered a copy of their applicable consent/ROI, and this requirement has been incorporated into the admission and consent process for all incoming clients.
The Clinical Director will review client records in real time to verify that clients are offered copies of their consents and ROIs and that the client's acceptance or declination is appropriately documented. Any deficiency identified through review will be corrected immediately, and staff will receive additional education as necessary to maintain ongoing compliance. |