INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on July 1, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Reset BC 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(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of administrative information, the facility failed to develop a comprehensive staff development program including policies and procedures for the program indicating who is responsible and the time frames for completion of an overall plan for addressing staff training needs.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
RESET BC LLC has implemented a structured staff development plan. Starting May 15th, each staff member will be provided with an individualized training plan, distributed annually. Completed training plans must be submitted to the Director by May 30th.
The Director will review and finalize all individual plans, ensuring completion by June 15th. Following this, the Director will compile and complete the organization's overall training plan, integrating both individual and agency-wide training objectives by July 1st.
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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 information, the facility failed to document an assessment of staff training needs for the July 2025 to June 2026 training year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director is responsible for evaluating staff training needs, with assessments to be completed annually by July 15th. To maintain ongoing compliance, the Director will perform semi-annual employee chart audits and maintain detailed records of all annual trainings. This will ensure all training requirements are met consistently. A mandatory staff meeting will also be held after assessment have been reviewed, to regroup and collaboratively determine the most effective and relevant trainings to support RESET's overall development.
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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 information, the facility failed to document an overall plan for addressing staff training needs for the July 2025 to June 2026 training year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
RESET BC LLC has implemented a structured staff development plan. Starting May 15th, each staff member will be provided with an individualized training plan, distributed annually. Completed training plans must be submitted to the Director by May 30th.
The Director will review and finalize all individual plans, ensuring completion by June 15th. Following this, the Director will compile and complete the organization's overall training plan, integrating both individual and agency-wide training objectives by July 1st.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a review of the physical plant, the facility failed to ensure cold foods were kept at or below 40 degrees Fahrenheit.
The refrigerator located in the first-floor kitchen had a facility thermometer which read 44 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
If the temperature rises above 40°F, staff are required to promptly notify the Director or Maintenance, take immediate steps to adjust the temperature, assess the safety of stored food items, and continue completing the daily temperature logs as part of daily routine procedure. New and improved thermometers have been purchased and placed in the refrigerators, and the fridge settings have been adjusted to a required temperature. Staff will also ensure that the fridge's temperature setting is assessed during each temperature check.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of administrative records and facility staff interview, the facility failed to conduct unannounced fire drills at least once a month.
No fire drills were conducted for the month of November 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will continue to be conducted and documented monthly, with all records maintained in a designated binder. Fire drills are coordinated and monitored by Life Skills staff, and the Director is notified at least one week in advance to ensure oversight and compliance.
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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 fire drill records, the facility failed to maintain a written fire drill record that includes all required components.
Fire drill records were reviewed from December 2024 to June 2025. All documented fire drills failed to include the exit route used, number of people evacuated, problems encountered and whether the 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
A revised fire drill form has been created to include additional details such as the exit route used, the number of individuals evacuated, any problems encountered, and confirmation of fire alarm and smoke detector operability. This updated form has replaced the previous version and is now stored in the designated binder for ongoing use and reference. The Life Skills Lead will retrieve the Fire Log book, which contains the daily census, and following each fire drill, will meet with the Director to review the completed forms. The Director will provide immediate sign-off.
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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 administrative information, the facility failed to document a policy and procedure for notifying the emergency contact for clients who discharge against facility advice.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
RESET BC has implemented a new format for the Discharge Follow-Up chart, which now includes the time emergency contacts are reached. Director will follow up with the client's emergency contact within 12 hours of the client's discharge. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of seven records.
Client #4 admitted on December 7, 2024 and discharge February 3, 2025. There was no consent to release information form for the funding source. Billing was confirmed in client record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Client EHR charts are audited weekly by either the Clinical Supervisor or the Director. As part of this process, the therapy team verifies that all necessary Releases of Information are on file and adds any additional ROIs relevant to the client's care. RESET BC has also implemented a policy requiring the client's funding source to be included in the essential ROI documentation at intake.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information, the facility failed to have and implement a written policy and procedure regarding the inspection of medication storage areas, including what is to be verified through the inspection, who inspects, how often, and in what manner it is to be recorded.
In addition, the facility failed to document the inspection of storage areas.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All storage areas are inspected by the Life Skills Lead every Monday morning. A new documentation form has been implemented to record these inspections, which is completed, initialed, and signed by the Life Skills Lead. The Director reviews and signs off on the weekly storage inspection checklist, and all completed checklists are compiled and maintained in a designated binder for reference and compliance.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of administrative information, the facility failed to have and implement a written policy and procedure for the methods for control and accountability of drugs, including who is authorized to remove drugs and the program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
RESET BC acknowledges the deficiency related to the lack of a formal written policy and procedure for the control and accountability of drugs. We have taken the following corrective actions of developing a policy and procedure and implementing protocols that will include receipts, logging of medications, safe storage and access control, administration, documentation of medication use, disposal of expired or discontinued medications, and drug count reconciliation procedures. The Director of RESET BC will be responsible for drafting, finalizing, and implementing the policy and procedures. The policy will be reviewed and approved by the leadership team to ensure ongoing compliance and prevent recurrence of this deficiency. Weekly audits of medication logs and inventory will be conducted by the Life Skills Lead or Director and will be placed in designated binder. Quarterly internal reviews of the drug control and accountability process will be completed by the Director. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of administrative information, the facility failed to have and implement a written policy and procedure for the security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
We have added to our policy and procedure that all staff involved in medication handling have been trained on the full medication administration process and have signed an acknowledgment form confirming their understanding. Clear, step-by-step instructions are provided to ensure proper medication adherence and compliance.
Medication storage areas are secured behind two locked doors to ensure safety and limit access.
A *Medication Incident Report Form* has been developed for staff to complete in the event of any discrepancies, concerns, or suspected breaches in drug security. A dedicated binder has been created to track incidents, monitor compliance, and identify areas for improvement.
Weekly audits of medication storage will be conducted by either the Director or the Life Skills Lead to ensure ongoing adherence to safety protocols. Any incident involving suspected drug misuse, loss, or theft will be reported immediately to the appropriate authorities and documented in accordance with DDAP regulations.
The Director of RESET BC is responsible for oversight, policy enforcement, staff training, and ongoing monitoring of medication security compliance.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of administrative information, the facility failed to develop and implement policies and procedures to respond to unusual incidents that includes ongoing monitoring of the corrective action plan.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
RESET will establish and implement a formal Policy and Procedure focused on the ongoing monitoring of corrective actions stemming from unusual internal incident reports. This policy will define the process to ensure all corrective actions are not only carried out but also consistently reviewed for compliance. The Director will be responsible for developing and implementing this policy. All incident reports and their associated corrective action plans will be reviewed by the Director within three business days of submission. A monitoring log will be maintained to document each incident, the corrective measures taken, implementation dates, and the results of any follow-up evaluations. The Director will perform monthly reviews of corrective actions to confirm their completion and continued compliance. All records will be maintained in a designated binder specifically for unusual incidents and corrective action tracking, available for review during audits and inspections. This policy will be reviewed and revised annually, or as needed, to ensure alignment with current regulatory requirements. Through this structured approach, RESET will maintain consistent oversight and accountability in the handling and resolution of unusual incidents.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative information and interviews with staff, the facility failed to inform the Department of an unusual incident. The facility reported several unusual incidents which occurred since opening in October 2024 that involved ambulance and fire personnel on site. The facility has not submitted any written unusual incident report to the Department at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In the event that police or fire services respond to the facility, the Director must be notified immediately. The staff member who made the 911 call is required to complete a written statement detailing the incident. Following notification, the Director will complete an online incident report and submit it to DDAP as required. A binder of unusual incidents will also be maintained in the office by the Director for documentation and future reference |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical examination in five of seven records reviewed.
The following clients had no documentation of a physical examination in their client record.
Client #1 admitted on December 3, 2024 and still a current client.
Client #3 admitted on December 11, 2024 and discharged on February 14, 2025.Client #4 admitted on December 7, 2024 and discharged on February 3, 2025.
Client #6 admitted on January 13, 2025 and discharged on March 25, 2025.
Client #7 admitted on March 25, 2025 and discharged on June 14, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Upon admission, the Life Skills Lead is responsible for scheduling all necessary appointments for the client, including ensuring that a physical examination is completed within the first 30 days. A standardized form has been created for clients to take to their physical appointment, and a copy of the completed form will be maintained in the client's paper chart for documentation and compliance purposes. Director will do monthly chart reviews to ensure that these appointments are met in compliance with Reset policies and procedures
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in seven of seven records reviewed.
There was no documentation on any treatment plan that work done by the client while in residential treatment was an integral part of treatment in all records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
RESET BC LLC has identified that "chores" have not been incorporated into Treatment Plans. Moving forward, "chores" will be included in every client's Treatment Plan. A formal notice has been issued to all clinicians outlining this requirement.
To ensure compliance, the Director will conduct weekly internal audits of Treatment Plans within the Electronic Health Record (EHR) system to verify that each client's plan includes the "chores" component.
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