INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Horizon Behavioral Health PLLC 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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 indicate the date of the annual fire extinguisher inspection via tag. The fire extinguisher in the kitchen was missing the tag.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The fire extinguisher and microwave have been removed from the kitchen area. The facility no longer maintains a designated kitchen area requiring the extinguisher that was cited during the inspection.
All remaining fire safety equipment within the facility has been reviewed to ensure required inspection documentation is present and current.
The Director will be responsible for conducting and documenting these quarterly reviews.
Compliance was achieved on 10/19/2026 and will be monitored on an ongoing basis through quarterly safety inspections. |
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 the review of the October 2025 - August 2026 fire drill logs, the facility failed to document whether the first alarm or smoke detector was operative during the December 2025 fire drill.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It appears that the submitted log was missing the smoke detector operation indicated data by administrative oversight. Program Director will continue to have the fire alarms set off during every drill and ensure the log is correctly maintained. This is effective as of 10/14/2026. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the October 2025 - August 2026 fire drill logs, the facility failed to prepare alternative exits to be used during fire drills. Of the eleven drills reviewed, ten used the front door as the exit route.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility developed a written Fire Drill Schedule requiring the use of alternate evacuation routes throughout the year.
Staff have been educated regarding the requirement to rotate evacuation routes and document the specific exit used during each fire drill.
Future fire drills will alternate between all available and safe emergency exits to ensure staff and occupants are familiar with multiple evacuation routes.
The Director will review each completed fire drill log to verify that alternate routes are being utilized and documented.
Compliance was achieved on 10/14/2026 and will be monitored through quarterly review of fire drill records. |