INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, R&D Center LLC 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director completed at least 12 clock hours of annual training during the facility ' s January 2024 through December 2024 training year. Employee #1 was hired as the Project Director on February 1, 2023. The personnel record documented 4 hours of annual training during the training year reviewed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will conduct routine audits of of training plans throughout the year to ensure employees are on pace to meet position training requirments
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguishers upon staff employment in one of one applicable personnel record reviewed.Employee # 4 was hired as a counselor on January 20, 2025 and was due to be trained in the use of fire extinguishers upon employment; however, the fire safety training was completed on November 13, 2025.This is a repeat citation from the December 6, 2024 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire safety training will be added to Employee onboarding checklist effective 1/1/2026. Executive Director will ensure that checlist is completed within first week of employment |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of one applicable personnel record reviewed.Employee #4 was hired as a counselor on January 20, 2025. The training to perform assigned tasks during emergencies was not provided until November 13, 2025.This is a repeat citation from the December 6, 2024 annual licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency readiness training will be added to Employee onboarding checklist effective 1/1/2026. Executive Director will ensure that checlist is completed within first week of employment |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure the individual treatment and rehabilitation plan was developed with the client and per the facility policy in seven of seven client records reviewed. The facility policy and procedure manual indicated the individual treatment and rehabilitation plan will be completed by the primary counselor within 14 days of intake. Client #1 was admitted on April 14, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by April 28, 2025; however, the plan was completed on May 7, 2025.Client #2 was admitted on May 5, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by May 19, 2025; however, the plan was completed on May 22, 2025. Additionally, there was no documentation the plan was developed with the client, as the client signed the plan on June 2, 2025.Client #3 was admitted on May 12, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by May 26, 2025; however, the plan was completed on June 6, 2025. Additionally, there was no documentation the plan was developed with the client, as the client signed the plan on August 28, 2025.Client #4 was admitted on April 3, 2025 and was discharged on August 11, 2025. The individual treatment and rehabilitation plan was due to be completed by April 17, 2025; however, the plan was completed on April 28, 2025. Additionally, there was no documentation that the plan was developed with the client. Client #5 was admitted on May 12, 2025 and was discharged on October 1, 2025. The individual treatment and rehabilitation plan was completed by May 26, 2025; however, there was no documentation that the plan was developed with the client.Client #6 was admitted on March 31, 2025 and was discharged on July 28, 2025. The individual treatment and rehabilitation plan was due to be completed by April 14, 2025; however, the plan was completed on April 18, 2025. Additionally, there was no documentation that the plan was developed with the client. Client #7 was admitted on August 14, 2025 and was discharged on October 31, 2025. The individual treatment and rehabilitation plan was due to be completed by August 28, 2025; however, the plan was completed on September 2, 2025. Additionally, there was no documentation that the plan was developed with the client, as the client signed the plan on September 15, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will conduct routine adits of charts to ensure that Master Treatment Plans are completed within compliance of the Policies and Procedures.
Chart audits began on 1/6/2026
Clinical Director will supervise all prmary therapists and train in time management strategies. Current staff was trained on the treatment plan ppolicy on 1/2/2026. All new hires will be trined on treatment plan policies within a week of hire date. |
709.93(a)(11) LICENSURE Client records
709.93. 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 and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable records reviewed. Client #6 was admitted on March 31, 2025 and was discharged on July 28, 2025. There was no documentation of follow-up information in the client record at the time of the inspection.Client #7 was admitted on August 14, 2025 and was discharged on October 31, 2025. There was no documentation of follow-up information in the client 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
Clinical Director will routinely audit charts to ensure compliance of the follow up policy and procedure. Clinical Director will train each Primary Therapist on submiting documentation in a timely manner.
Audits of charts to ensure follow ups are completed will begin 1/6/2026.
Current therapists were trained on follow up policy on 1/2/2026. All new hires will be trained on this policy during their first week of employment. |