INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 April 2024 through June 2025 fire drill records, the facility failed to document, on their written fire drill record, the amount of time it took for evacuation.
There was nothing indicating the amount of time it took for evacuation documented on the completed October 2024 fire drill record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff who may complete fire drill record were reminded of the need for accuracy and completeness. Staff completing fire drill record will submit the record to management each month for review prior to filing. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to maintain a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relation to its stated goals and objectives.
The facility had a hybrid system of electronic and paper client records. The Licensing Representative requested the complete paper records first thing on the morning of the inspection, and it took approximately two and a half hours for facility staff to retrieve the requested client records, which is inefficient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The finding was reviewed with staff who work with paper records. Staff will ensure that, at all times, charts contain all required documentation and are stored in office file cabinets for efficient retrieval. Program management will conduct monthly chart audits to ensure adherence to the program's goals and objectives, as well as POC. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 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 sixty days in two of four applicable client records reviewed.
Client # 8 was admitted on December 11, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on January 9, 2025 and the first update was due no later than March 9, 2025; however, the update was not completed until March 27, 2025.
Client # 14 was admitted on February 19, 2025 and was discharged on May 23, 2025. The individual treatment and rehabilitation plan was completed on March 20, 2025 and the first update was due no later than May 20, 2025; however, the update was not completed until May 29, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The finding was reviewed with appropriate staff. Program management and clinical staff reviewed timeframe requirements for treatment and rehabilitation plans, how the dates of the plans are determined, and how the electronic health record being utilized captures and records dates. Program management will conduct monthly chart audits to ensure adherence to licensing regulations and POC. |