INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted on April 13, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the off-site complaint investigation, The Behavioral Wellness Center at Girard was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.26 (a) LICENSURE Personnel Management
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
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Observations
Based on a review of employee records, the Disciplinary Actions policy, and other administrative documentation, the facility failed to implement personnel policies and procedures.Per the Disciplinary Actions policy, the progression of disciplinary actions is verbal warning, written warning, suspension, and termination. Any infraction of work rules should result in some form of corrective or disciplinary action. The supervisor should write a detailed description of the issue.Administrative documentation consisting of texts, emails, and supervisory sessions indicates that verbal altercations occurred between two employees in June 2024 and November 2024. These employees received written verbal warnings in June 2024. There was no documentation of disciplinary actions taken for the verbal altercation in November 2024.
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Plan of Correction
Supervisors will be re-educated on the Behavioral Wellness Center Disciplinary Policy and the importance of complying with the policy.
Responsible Staff: Supervisors, Human Resource Manager and respective Vice President.
Supervisor will document progression of respective disciplinary infractions according to The Behavioral Wellness Center Disciplinary Policy.
Responsible Staff: Supervisors and respective Vice President.
Supervisor will follow-up with Human Resource (when in doubt) for guidance regarding staff violation of the disciplinary process to ensure compliance with appropriate documentation as outlined in the Disciplinary Policy.
Responsible Staff: Supervisors and Human Resource Manager.
Supervisor will document disciplinary actions taken for all violations of the Disciplinary Policy.
Responsible Staff: Supervisors.
HR Manager will conduct focus review of 100% of Disciplinary Action documentation during a 2-month period begin 5/1/26 to ensure that the Disciplinary Action policy is followed.
Responsible Staff: Human Resource Manager
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709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on a review of employee records, the Code of Conduct, the Code of Ethics and other administrative documentation, the facility failed to follow its rules of conduct.Per the Code of Conduct, business is to be conducted in a manner which is ethical and professional.Per the Code of Ethics, residents, employees, volunteers and visitors deserve to be treated with dignity, respect, and courteousness.Administrative documentation consisting of texts, emails, and supervisory sessions, between June 2024 and November 2024, indicates that verbal altercations occurred between two employees in front of the residents.
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Plan of Correction
Supervisors will be re-educated on the Behavioral Wellness Center Code of Conduct Policy and the importance of complying with the policy.
Responsible Staff: Supervisors, Human Resource Manager and respective Vice President.
Supervisor will document progression of respective disciplinary infractions according to The Behavioral Wellness Center Code of Conduct Policy.
Responsible Staff: Supervisors and respective Vice President.
Supervisor will follow-up with Human Resource (when in doubt) for guidance regarding staff violation of the Code of Conduct Policy to ensure compliance with appropriate documentation as outlined in the policy.
Responsible Staff: Supervisors and Human Resource Manager.
Supervisor will document disciplinary actions taken for all violations of the Code of Conduct Policy.
Responsible Staff: Supervisors.
HR Manager will conduct focus review of 100% of documentation of Code of Conduct during a 2-month period effective 5/1/2026 to ensure that the Code of Conduct policy is followed.
Responsible Staff: Human Resource Manager.
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