INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 22-23, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Stepping Stones Unit @ Meadville Medical Center 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 personnel records, the facility failed to develop a written individual training plan for the 2025 training year in five of five records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Supervisor will return to utilizing an educational training plan for each individual that was utilized in the past. These training plan, which are on paper, will be initiated early in the calendar year and can be amended if necessary throughout the training year. This gives a list of possible courses that are pertinent to all staff and also encompass things being seen in the patient populations about which staff would like to become more proficient. The form will also have lists of the required core courses and other things such as CPR training that needs to occur annually or more frequently. Staff will have spaces to write in things they are hoping to achieve that year as goals and the educational steps needed to achieve those such as attaining specific certifications or working toward licensure. The Program Supervisor and Facility Director will review these plans throughout the year and also query staff in general to respond with additional goals or any difficulties accessing the education they seek. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one employee received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of one record.
Staff #4 was hired as a counselor on December 19, 2023 and still employed. The communicable disease training was due to be completed no later than December 19, 2024 but was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The staff member referenced has signed up for the 4 hour training TB/STD/Hepatitis scheduled in person in Kitanning PA on October 29, 2025. All staff were reminded at a team meeting by the Program Supervisor after the survey had been completed, that within one year of hire core courses must be completed. Staff will be assisted by the Program Supervisor if finding an available course is problematic or if staff needs to access the courses on the DDAP site or the unit or facility may need to create and provide the course. the facility will via the Program Supervisor will emphasize at the beginning of each year and during orientation of any new staff, of the necessity to complete these courses within the regulated time frame. To ensure this deficiency does not recur, the training plans will also state the need for the core courses and if staff members have already completed these this will be checked on the form. If they have not and are scheduled, that too will be documented on the form. If they are not scheduled, as noted above the Program Supervisor will assist staff in getting scheduled for available trainings. |
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 fire drill records, the facility failed to maintain a written fire drill record that includes all required information for completed fire drills.
Reviewed fire drill records from September 2024 to August 2025. Fire drill logs completed in November 2024 and July 2025 failed to include the exit route used; December 2024 and May 2025 failed to include the amount of time it took to evacuate; and May 2025 failed to include the number of people evacuated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting immediately after the close of the inspection, any fire drills that occur in this building will be reviewed in detail by the Program Supervisor and/or Facility Director to make sure the log reports include 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. Those patients in acute detox or with medical problems hampering mobility or that make moving them a safety risk will not be evacuated and the reasons for this will be documented by the staff in the report following the cessation of the drill. Each patient who did not evacuate will also have this documentation in their chart. The fire drill policy and procedure will be amended to contain these changes. |