INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 28, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Brightside Health Inc. 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) (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 ensure all staff were instructed in the use of the fire extinguisher upon staff employment in two of four personnel records reviewed.
Employee # 1 was hired as the project director and facility director on March 25, 2025. The training in the use of the fire extinguisher was not completed until October 3, 2025.
Employee # 4 was hired as a counselor on August 1, 2025. The training in the use of the fire extinguisher was not completed until September 23, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Brightside Health will ensure all staff complete required training, including fire extinguisher training, which are tracked through our Learning Management System (LMS).
For the two identified employees, the training was not assigned at the time of hire for this facility but was assigned and completed as soon as identified.
All required training will be completed within two weeks of hire during the onboarding process and prior to any client contact. To ensure ongoing compliance, the Provider Services department will monitor LMS records to verify that all required training, including fire extinguisher instruction, are assigned and completed within the required timeframe.
Compliance will conduct quarterly internal audits of LMS completion records and personnel files to confirm timely completion and documentation.
The corrective action will be effective no later than 12/1/2025 and monitoring procedures will continue on a quarterly basis thereafter to ensure sustained compliance with §705.28(c)(4).
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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 all personnel on all shifts were trained to perform assigned tasks during emergencies in two of four personnel records reviewed.
Employee # 1 was hired as the project director and facility director on March 25, 2025. The training to perform assigned tasks during emergencies was not completed until October 3, 2025.
Employee # 4 was hired as a counselor on August 1, 2025. The training to perform assigned tasks during emergencies was not completed until September 23, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Brightside Health will ensure all staff complete required training, including emergency procedure training, which are tracked through our Learning Management System (LMS).
For the two identified employees, the training was not assigned at the time of hire for this facility but was assigned and completed as soon as identified.
All required training will be completed within two weeks of hire during the onboarding process and prior to any client contact. To ensure ongoing compliance, the Provider Services will monitor LMS records to verify that all required training, including emergency procedure training, are assigned and completed within the required timeframe.
Compliance will conduct quarterly internal audits of LMS completion records and personnel files to confirm timely completion and documentation.
The corrective action will be effective no later than 12/1/2025 and monitoring procedures will continue on a quarterly basis thereafter to ensure sustained compliance with §705.28(d).
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