INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2026 and March 26, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Horsham Clinic 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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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
As of the date of the physical plant inspection, which was conducted on March 26, 2026 at approximately 10:20 am, there was a fire extinguisher, located in the kitchen, that was last inspected in January 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Action: The CEO, COO, and Director of Performance Improvement reviewed this finding. The identified fire extinguisher in the kitchen was immediately inspected and serviced by the certified fire extinguisher company that The Horsham Clinic partners with on March 27th, 2026. The extinguisher was confirmed to be in proper working order, and an updated inspection tag was applied. The maintenance department was re-educated about reporting non-compliant fire extinguishers to the CEO or other designee to ensure ongoing compliance. All corrective actions were completed by March 27, 2026.
Monitoring: Maintenance Department will continue to conduct monthly rounds to inspect and ensure all fire extinguishers are in proper working order.
Responsible Party: Director of Plant Operations
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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 allowed for the efficient retrieval of data needed to measure the project's performance.
A request to provide the Department Representative with a list of the facility ' s discharged clients, including the client ' s activity and type of discharge, for the timeframe covering March 13, 2025 to the date of the inspection. The facility was able to provide a list of discharged clients; however, facility staff were unable to retrieve or identify the discharged clients ' activities or types of discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Action: The CEO, COO, and Director of Performance Improvement reviewed this finding. The facility conducted an immediate review of reporting capabilities of our electronic medical record (EMR). It was identified that there is reporting capability within our EMR to pull the data requested. The Director of Performance Improvement was educated on how and where to locate the report.
Monitoring: The Director of Performance Improvement will run a report monthly to collect the relevant data.
Responsible Party: The Director of Performance Improvement
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