INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TrueNorth Wellness Services 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records and staff training records, the project failed to instruct all staff in the use of the fire extinguisher upon employment in two of four records reviewed. Employee #2 was hired as a facility director on December 9, 2025, and was current in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training as of the date of the licensing inspection.Employee #4 was hired as a counselor on December 9, 2025, and was current in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training as of the date of the licensing inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The following steps will be put into place to ensure all staff are instructed in the proper use of the fire extinguisher:
1. The Senior Director of Treatment and Prevention Services will ensure fire extinguisher training is assigned and completed in the DATIS system on the day of New Hire Orientation when a new SUT OP Manager is hired.
2. The SUT OP Manager will ensure fire extinguisher training is assigned and completed in the DATIS system on the day of New Hire Orientation of new SUT staff being hired.
3. Training certificates of completion can be retrieved from the DATIS system.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records and staff training records, the project failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in two of four records reviewed. Employee #2 was hired as a facility director on December 9, 2025, and was current in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this as of the date of the inspection.Employee #4 was hired as a counselor on December 9, 2025, and was current in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this as of the date of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The following steps will be put into place to ensure all staff are instructed on emergency training:
1. The Senior Director of Treatment and Prevention Services will ensure emergency training is assigned and completed at New Hire Orientation when a new SUT OP Manager is hired.
2. The SUT OP Manager will ensure emergency training is assigned and completed at New Hire Orientation when new SUT staff are hired.
3. The emergency procedures on New Hire Orientation Day will be assigned from Datis.
4. In addition, after New Hire Orientation, staff receive CPR/Basic First Aid training which consists of 4 hours of online training via the Red Cross and 1 hour of demonstration of skills with a Red Cross approved instructor.
The completion of monthly fire drills started on February 12, 2026. |