INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2025 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:
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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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons completed a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in one of four applicable personnel records reviewed.
Employee #5 was hired as a counselor on June 28, 2024. The TB/STD and other health topics training were due to be completed no later than June 28, 2025. There was no documentation in the record indicating the TB/STD training was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 will register for A TB/STI training by 9/1/2025.
All state mandated trainings including HIV/AIDS and TB/STD will be added to each individual's training plan and signed off by the supervisor to ensure that the requirement is clear.
Director will review personnel charts to monitor training hours monthly throughout the year to ensure that training requirements are met. |
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.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility were unobstructed.
At the time of the physical plant inspection, conducted at approximately 1:30pm, the second-floor's secondary window exit was obstructed by a bathroom toilet stall. Additionally, the third-floor's secondary window exit was obstructed by a bathtub.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will will work with RHD Property manager to identify a contractor by 7/15/2025 to complete the work of removing the partition covering the fire exit on the second floor and the bathtub covering in the third floor. Work to be complete by 9/1/2025.
Life Skills Professionals will ensure that exits are not blocked during their hourly rounds of the building and Office Manager and Director will monitor through regular building inspections. |
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 facility's policy and procedure manual and client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of two applicable client records reviewed.
The facility's policy and procedure manual stated the program will contact the participant's emergency contact within 12 hours of when the participant leaves against facility advice.
Client #4 was admitted to the residential activity activity on June 18, 2024 and was discharged against facility advice on October 18, 2024. There was no documentation of an attempted notification to the emergency contact in the record at the time of the inspection.
Client #5 was admitted to the residential activity on August 2, 2024 and was discharged against facility advice on September 14, 2024. There was no documentation of an attempted notification to the emergency contact in the record 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 facility's policy of contacting the emergency contact was reviewed with clinical staff. Therapists will be responsible for contacting the residents emergency contact when he resident leaves against facility advice and will document all contacts in a note in the electronic health record. In the event that a therapist is not available in the timeframe, Life Skills Professional staff will contact the emergency contact and document the contact on the identified form.
Director will monitor as needed to ensure that the policy is followed and documentation is submitted. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in five of seven applicable client records reviewed.
Client #1 was admitted to the residential activity on June 4, 2024 and was active at the time of the inspection. A release of information form to the emergency contact was signed and dated by the client on June 4, 2025; however, there was no name of the person, agency or organization to whom the disclosure was to be made included on the release form.
Client #3 was admitted to the residential activity on December 9, 2024 and was active at the time of the inspection. A release of information form titled "medical/dental" was signed and dated by the client on December 9, 2024; however, there was no name of the person, agency or organization to whom the disclosure was to be made included on the release form.
Client #5 was admitted to the residential activity on August 2, 2024 and was discharged on September 14, 2024. A release of information form titled "medical/dental" was signed and dated by the client on August 21, 2024; however, there was no name of the person, agency or organization to whom the disclosure was to be made included on the release form.
Client #6 was admitted to the residential activity on January 3, 2025 and was discharged on March 10, 2025. A release of information form titled "medical/dental" was signed and dated by the client on January 3, 2025; however, there was no name of the person, agency or organization to whom the disclosure was to be made included on the release form.
Client #7 was admitted to the residential activity on October 11, 2024 and was discharged on April 4, 2025. A release of information form titled "medical/dental" was signed and dated by the client on January 24, 2025; however, there was no name of the person, agency or organization to whom the disclosure was to be made included on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Generic "medical and dental" consents utilized by nursing staff were removed from intake packets on 7/1/25 and replaced with consents requiring the name of a specific person, role, and phone number. The procedure for properly filling out consents will be reviewed with all staff by 8/1/2025. Supervisors including Office Manager, Nurse Manager, and Director will monitor for compliance by regularly reviewing consents for these standards. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in four of seven client records reviewed.
Client #3 was admitted to the residential activity on December 9, 2024 and was active at the time of the inspection. A release of information form titled "medical/dental" was signed and dated by the client on December 9, 2024; however, there was no additional documentation indicating the release form was offered to the client.
Client #5 was admitted to the residential activity on August 2, 2024 and was discharged on September 14, 2024. A release of information form titled "medical/dental" was signed and dated by the client on August 21, 2024; however, there was no additional documentation indicating the release form was offered to the client.
Client #6 was admitted to the residential activity on January 3, 2025 and was discharged on March 10, 2025. A release of information form titled "medical/dental" was signed and dated by the client on January 3, 2025; however, there was no additional documentation indicating the release form was offered to the client.
Client #7 was admitted to the residential activity on October 11, 2024 and was discharged on April 4, 2025. A release of information form titled "medical/dental" was signed and dated by the client on January 24, 2025; however, there was no additional documentation indicating the release form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be retrained in the process of properly filling out consents by 8/1/2025, including having the client initial that they accepted or rejected a copy of the consent form.
Supervisors including Office Manager, Nurse Manager, and Director will review consents regularly to monitor for compliance. |
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.
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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 five applicable client records reviewed.
Client #1 was admitted to the residential activity on June 4, 2024 and was active at the time of the inspection. A treatment plan update was completed on April 27, 2025 and the next update was due to be completed no later than May 27, 2025; however, the update was completed on June 19, 2025.
Client #2 was admitted to the residential activity on October 2, 2024 and was active at the time of the inspection. A treatment plan update was completed on April 30, 2025 and the next update was due to be completed no later than May 30, 2025; however, the update was completed on June 19, 2025.
Client #3 was admitted to the residential activity on December 9, 2024 and was active at the time of the inspection. A treatment plan update was completed on March 31, 2025 and the next update was due to be completed no later than April 30, 2025; however, the update was completed on May 6, 2025.
Client #7 was admitted to the residential activity on October 11, 2024 and was discharged on April 4, 2025. A treatment plan update was completed on December 18, 2024 and the next update was due to be completed no later than January 18, 2025; however, the update was completed on February 6, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Timelines for documentation were reviewed with clinical staff on 7/2/2025 and therapists will submit all treatment plans before 30 days to ensure compliance and allow for supervisor to review and adjustments to be made if necessary.
Director will monitor documentation timelines through weekly and monthly chart audits and daily review of documentation. |
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 patient records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in one of two applicable client records reviewed.
Client #7 was admitted to the residential activity on October 11, 2024 and was discharged on April 4, 2025. There was no documentation, in the record, of follow-up information at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Timelines for clinical documentation including client follow-up were reviewed with the clinical team on 7/2/2025. Therapist will document follow-up with the client, efforts to follow up, and any barriers on the client follow-up form to be entered into the client record within 30 days of discharge.
Director will monitor through weekly and monthly chart audits. |