INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 24, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD / New Start II 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:
|
Plan of Correction
|
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
|
Observations
Based on a review of personnel records, the facility failed to ensure each annual written individual training plan was based upon the employee's previous education, experience, current job functions, and performance in three of five applicable personnel records reviewed.
Employe # 3 was hired as a clinical supervisor on February 2, 2026. The individual training plan was completed on June 30, 2025; however, the training plan was not individualized and based upon the employee's previous education, experience, current job functions, and performance as the plan was identical to the training plan for the counselors.
Employee # 4 was hired as a counselor on June 28, 2024. The individual training plan was completed on June 30, 2025; however, the training plan was not individualized and based upon the employee's previous education, experience, current job functions, and performance as the plan was identical to the training plan for the clinical supervisor and the other counselor.
Employee # 5 was hired as a counselor on November 16, 2023. The individual training plan was completed on June 30, 2025; however, the training plan was not individualized and based upon the employee's previous education, experience, current job functions, and performance as the plan was identical to the training plan for the clinical supervisor and the other counselor.
These findings were reviewed with facility staff at the time of the inspection.
|
Plan of Correction
Program Director, Clinical Manager, and Residential manager will hold supervision with their perspective employees to review and individualize their Individual Training PLans. This will be completed by 07/31/2026. All staff will have ongoing supervisions with their perspective supervisors to ensure training plans are individualized |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to ensure the project director completed at least 12 clock hours of training during the facility's July 1, 2024 through June 30, 2205 training year in one of one applicable personnel record reviewed.
Employee # 2 was hired as the facility director on August 14, 2023. The personnel record documented 7.17 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director is scheduled to complete 12 hours of training for the 2026-2027 training year, on September 22 and September 23.
Effective immediately, CLinical Supervisor will complete supervisions with therapists to review the required training hours and to develop a timeline to have all trainings completed. This will be monitored through ongoing supervisions. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
|
Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor.
At the time of the inspection, conducted on June 24, 2026 at approximately 2:15 p.m., there were several cases of bottled water stored directly on the basement floor.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective immediately, Residential Manager will assign staff to organize storage in the basement to ensure no food items are on the floor. Maintaining organization in the basement will be a part of the daily environmental rounds. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
Based on a physical plant inspection, the facility failed to ensure all stairways, hallways, and exits from the nonresidential facility were unobstructed.
At the time of the inspection, conducted on June 24, 2026 at approximately 2:15 p.m., the egress door in the basement was locked and only able to be unlocked with a key. The key was not kept near the exit; therefore, during an emergency, the basement door would not be able to be opened by any individual.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The program placed the key to the basement egress near the door ensuring the exit is not obstructed. Residential Manager will ensure continued compliance by assigning a Life Skills Professional to ensure the key is visible through daily facility checks |
705.10 (b) (3) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
|
Observations
Based on a physical plant inspection and conversation from facility staff, the facility failed to repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperable.
At the time of the inspection, there was a smoke detector that was continuously beeping, indicating a low battery, and could be heard throughout the duration of the entire inspection. Facility staff confirmed to the Licensing Representative that the smoke detector has been beeping for longer than 48 hours.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Smoke detector has been changed. Additional smoke detectors will be purchased by 07/31/2026 to ensure any inoperable smoke detectors are repaired within the 48 hours of the time the fire alarm is found to be inoperable. The Program Director will purchase the additional smoke detectors by 07/31/2026 |
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.
|
Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.
The facility policy and procedure manual stated the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 7 was admitted on September 4, 2025 and was discharged against medical advice on November 4, 2025. There was no documentation in the record indicating the emergency contact was notified of the client's discharge.
This is a repeat citation from the June 30, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 07/31/2026, all staff will be trained on the policy on contacting a clients emergency contact within 12 hours after the client AFAs from treatment. At the time of AFA, the therapist will contact the Emergency Contact and document on the Emergency Contact Form. In the event the therapist is not able to contact the Emergency Contact with in the 12 hours, the Life Skills professional will contact the Emergency Contact and document on the Emergency Contact Form.
Clinical Manager and Program Director will
ensure training is held and will monitor for compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 2 was admitted on February 12, 2026 and was still active at the time of the inspection. There was evidence of disclosures to a laboratory at least 17 times from February 15, 2026 through the date of the inspection; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Active client will meet with Program Director to sign the release of information for the lab by 08/04/2026.
By 08/15/26, All staff will be retrained by the CLinical Manager, on how to properly complete a Release of Information. This will include documentation of the specific information to be disclosed. The Program Director will review all Releases of Information at the time of intake to ensure all Releases have been completed.
|
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of seven client records reviewed.
Client # 1 was admitted on December 9, 2025 and was still active at the time of the inspection. The release of information forms to an emergency contact and another treatment provider were signed by the client on December 9, 2025; however, both release forms did not include documentation of the specific information to be disclosed.
Client # 3 was admitted on March 25, 2026 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client on March 25, 2026; however, the release form did not include documentation of the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Active client will meet with the Program Director to reivew and complete the consent form by 08/04/2026. This will be documented in the cluients chart.
By 08/15/2026, All staff will be retrained by the Clinical Manager, on how to properly complete a Release of Information. This will include documentation of the specific information to be disclosed. Program Director will review all releases of information at time of intake and every month to ensure the forms have been completed correctly |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in two of seven client records reviewed.
Client # 1 was admitted on December 9, 2025 and was still active at the time of the inspection. The release of information forms to an emergency contact and another treatment provider were signed by the client on December 9, 2025; however, both release forms did not include documentation of the purpose of disclosure.
Client # 3 was admitted on March 25, 2026 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client on March 25, 2026; however, the release form did not include documentation of the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Active client will meet with the Porgram Director to add the purpose of the disclosure to his releasee of information by 08/04/2026. This will be documented inthe clients chart.
By 08/15/2026, All staff will be retrained by the Clinical Manager, on how to properly complete a Release of Information. This will include documentation of the specific information to be disclosed. This will be documented as a supervision. PRogram Director and Clinical Manager will monitor for ongoing compliance. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of the facility policy and procedure manual and client records, the facility failed to document, as part of their intake procedures, a preliminary treatment plan, in two of six applicable client records reviewed.
The facility policy and procedure manual stated that the preliminary treatment plan will be completed within seventy-two hours of admission.
Client # 2 was admitted on February 12, 2026 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed no later than February 15, 2026; however, the treatment plan was not completed until February 26, 2026.
Client # 5 was admitted on December 11, 2025 and was discharged on June 8, 2026. The preliminary treatment plan was due to be completed no later than December 14, 2025; however, the treatment plan was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective immediately, Clinical Manager will hold a supervision with therapists to ensure they are completing the preliminary treatment plan within 72 hours and are documenting the completion of the plan in the individual notes. The clinical Manager and Program Director will review chart documentation to ensure compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of the facility policy and procedure manual and client records, the facility failed to develop an individual treatment and rehabilitation plan in three of six applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 30 days of admission.
Client # 2 was admitted on February 12, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than March 14, 2026; however, the treatment plan was not completed until March 19, 2026.
Client # 3 was admitted on March 25, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than April 24, 2026; however, the treatment plan was not completed until May 6, 2026.
Client # 5 was admitted on December 11, 2025 and was discharged on June 8, 2026. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective Immediately, Clinical manager will meet with therapists to review the treatment plan timeline. This will be a documented supervision. Clinical Manager and Program Director will monitor via chart checks to ensure compliance with program policy. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in four of six applicable client records reviewed.
Client # 1 was admitted on December 9, 2025 and was still active at the time of the inspection. The individual treatment plan was completed on December 31, 2025 and the first update was due to be completed no later than January 30, 2026; however, the update was completed on February 7, 2026. Additionally, a treatment plan update was completed on April 8, 2026 and the next update was due on May 8, 2026; however, the update was not completed until May 21, 2026.
Client # 2 was admitted on February 12, 2026 and was still active at the time of the inspection. A treatment plan update was completed on April 14, 2026 and the next update was due to be completed no later than May 14, 2026; however, the update was completed on May 21, 2026.
Client # 4 was admitted on September 30, 2025 and was discharged on March 12, 2026. A treatment plan update was completed on December 16, 2025 and the next update was due to be completed no later than January 15, 2026; however, the update was not completed prior to discharge.
Client # 5 was admitted on December 11, 2025 and was discharged on June 8, 2026. A treatment plan update was completed on April 10, 2026 and the next update was due to be completed no later than May 10, 2026; however, the update was completed on May 22, 2026.
This is a repeat citation from the June 30, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective Immediately, Clinical manager will meet with therapists to review the treatment plan timeline. This will be a documented supervision. Clinical Manager and Program Director will monitor via chart checks to ensure compliance with program policy. |