INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CONCERN Profession Services for Children, Youth, and Families 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 the review of personnel records and the project's policies and procedures, the project failed to document a written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor within thirty days of hire and yearly in January thereafter, per facility policy, in two out of two records reviewed.
Employee #1 was hired on July 1, 2025, and was to have an annual individual training plan documented by August 1, 2025; however, an annual individual training plan was not documented in the personnel record at the time of the licensing inspection.
Employee #2 was hired on May 5, 2025, and was to have an annual individual training plan documented by June 5, 2025; however, an annual individual training plan was not documented in the personnel record at the time of the licensing inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The supervisor will have a discussion with the employee to review the skill level and individualized training needs by 6/24/2026. This discussion will be documented in the employees's file.
All overdue trainings will be completed withing 90 days, by 9/24/2026.
CONCERN's Training Administrator will build all training plans into Relias by 7/24/2026, CONCERN's Learning Management System, to ensure that all future trainings in the training plans are completed by the due date.
The supervisor will monitor timely training completion on an ongoing basis through various mechanisms, such as reviewing Relias report emails and reviewing the employee's Relias trainings due at each monthly supervision.
If staff do not adhere to the training plan due date requirements, the supervisor will meet with the staff to outline a corrective action plan to ensure staff meet the expectations. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from August 2025 through March 2026, the facility failed to conduct an unannounced fire drill during the months of August 2025, September 2025, October 2025, January 2026, February 2026 and March 2026.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Region Director will communicate the monthly unannounced fire drill regulatory requirement to both the Supervisor and the Office Manager by 6/24/2026.
Monthly fire drill reports will be added to the Towanda Fire Drill Binder on 6/24/2026.
Monthly unannounced fire drills will begin in July 2026 and will continue monthly ongoing.
Per the existing process, the fire drill completion is monitored at monthly Safety Committee Meetings to ensure compliance.
If staff do not adhere to the fire drill requirements, the supervisor will meet with the staff to outline a corrective action plan to ensure staff meet the expectations. |