INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 3, 2025 through September 4, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, Inc. 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(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 of ten applicable employees received a minimum of 6 hours of HIV/AIDS training using a Department approved curriculum within the regulatory timeframe.
Employee # 10 was hired as a support staff member on November 29, 2022 and was due to have the communicable disease trainings no later than November 29, 2024. However, the personnel record did not contain documentation of the completion of the HIV/AIDS training as of the date of the inspection.
This is a repeat citation from the August 31, 2023 and August 16, 2024 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A root cause analysis was
conducted identifying a
systematic error . When training
plans were implemented in our
electronic system at the end of October 2023, the due
dates were calculated based on
enrollment in training plans
rather than hire date so anyone
hired prior to the
implementation of the system/
training plans had the incorrect
due dates (2 years from
enrollment rather than 2 years
from date of hire). This affected
all system alerts and tracking
reports that were being utilized
for compliance checks. Since
training plans are assigned at
employee orientation, anyone
hired after the implementation of
these plans was not affected and
should be in compliance with all
required trainings.
The responsibility of ensuring staff training compliance is now shifting from HR to the CFO. At this time, the CFO is
designating the Assistant to the Director of Operations and the Compliance Officer as being the responsible parties. These parties will ensure that the systematic error in the electronic training system is corrected, review all training files for staff hired prior to November 2023, ensure any and all identified past due trainings that resulted from the systematic error are completed within the next 30 days to bring facility fully into compliance with training requirements, review all other staff training files to ensure there are no other issues with training plans implemented in the electronic system, and revamp tracking system to ensure the routine and accurate review of training compliance. Any identified issues with staff will be brought to department supervisor and CFO in timely fashion so that they may be addressed and corrected prior to the due dates for the required trainings to ensure ongoing compliance. The CFO will then meet with designated staff on a quarterly basis to
ensure that staff are in compliance by completing their trainings within the
time-frame required by DDAP and the systems in place at the facility are effective.
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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 physical plant inspection, the facility failed to ensure that frozen food was kept at or below 0 degrees, as the temperature for the standing freezer in the Dry Food Storage Room was measured at 5.5 degrees.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Food Services changed the
temperature on the freezer to reflect zero
degrees fahrenheit.
The freezer temperature will be monitored by the Food Services Director on a daily basis and a daily log will be kept to ensure that the temperature does not go above 0 degrees fahrenheit. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed within 48 hours of service, per facility policy, in three of eight records reviewed.
Client # 1 was admitted on November 20, 2024 and was discharged on January 7, 2025. The record contained progress notes for individual sessions that occurred on December 10, 2024, and December 30, 2024, that were not completed until December 27, 2024, and January 8, 2025, respectively.
Client # 4 was admitted on April 1, 2025 and was discharged on June 26, 2025. The record contained progress notes for individual sessions that occurred on April 10, 2025, and June 16, 2025, that were not completed until April 17, 2025, and June 23, 2025, respectively.
Client # 8 was admitted on June 17, 2025 and was active at the time of the inspection. The record contained progress notes for individual sessions that occurred on July 22, 2025, and August 14, 2025, that were not completed until July 27, 2025, and August 19, 2025, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Administration and the Clinical Director met to go over the policy and procedures for progress notes.
The policy was updated on 9/10/25 to reflect that progress notes will be completed within 5 days of the service/activity
This will be monitored by the Compliance Officer on a routine basis and any trends with staff will be reported to the Clinical Director and/or assigned clinical supervisor to ensure that it is addressed.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 7 days of discharge, per facility policy, in three out of three applicable records reviewed.
Client # 2 was admitted on December 16, 2024 and was discharged on March 16, 2025. Follow-up information was not documented in the record until March 27, 2025.
Client # 3 was admitted on January 7, 2025 and was discharged on April 9, 2025. Follow-up information was not documented until March 20, 2025.
Client # 5 was admitted on April 24, 2025 and was discharged on July 23, 2025. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will meet with the clinical staff to remind them that all
follow-ups are to be completed within 7 days of discharge.
This will be monitored by the Compliance Officer on a routine basis and any trends with staff will be reported to the Clinical Director and/or assigned clinical supervisor to ensure that it is addressed.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on the review of personnel records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction for mandatory communicable disease training was submitted and approved by the Department for the August 31, 2023, and August 16, 2024, annual licensing inspections. Mandatory communicable disease trainings was again found to be a deficiency in the September 3, 2025 through September 4, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A root cause analysis was
conducted identifying a
systematic error . When training
plans were implemented in our
electronic system at the end of October 2023, the due
dates were calculated based on
enrollment in training plans
rather than hire date so anyone
hired prior to the
implementation of the system/
training plans had the incorrect
due dates (2 years from
enrollment rather than 2 years
from date of hire). This affected
all system alerts and tracking
reports that were being utilized
for compliance checks. Since
training plans are assigned at
employee orientation, anyone
hired after the implementation of
these plans was not affected and
should be in compliance with all
required trainings.
The responsibility of ensuring staff training compliance is now shifting from HR to the CFO. At this time, the CFO is
designating the Assistant to the Director of Operations and the Compliance Officer as being the responsible parties. These parties will ensure that the systematic error in the electronic training system is corrected, review all training files for staff hired prior to November 2023, ensure any and all identified past due trainings that resulted from the systematic error are completed within the next 30 days to bring facility fully into compliance with training requirements, review all other staff training files to ensure there are no other issues with training plans implemented in the electronic system, and revamp tracking system to ensure the routine and accurate review of training compliance. Any identified issues with staff will be brought to department supervisor and CFO in timely fashion so that they may be addressed and corrected prior to the due dates for the required trainings to ensure ongoing compliance. The CFO will then meet with designated staff on a quarterly basis to
ensure that staff are in compliance by completing their trainings within the
time-frame required by DDAP and the systems in place at the facility are effective.
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