INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, GPHA Al-Assist Behavioral Health Care Center 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 instruct all staff in the use of fire extinguishers upon staff employment in one of two applicable personnel records reviewed.
Employee # 6 was hired as a counselor on June 2, 2025. There was documentation in the personnel record indicating the fire extinguisher training was not completed until August 1, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with standard 705.28. Fire safety. (c) Fire extinguishers. The nonresidential facility shall: (4) Instruct staff in the use of the fire extinguisher upon staff employment.
Following the site visit, a meeting was held with the Site's Leadership Team along to discuss the findings of the audit. Standard 705.28 (c)(4) was reviewed with the Site's Leadership Team to ensure that everyone was clear on the requirements of the standard, acknowledging our failure to meet the standard, and agreed as to how failure to meet standard 705.28 (c)(4) will be avoided moving forward.
The Director of Training and Development was instructed by the CBHO to place the Fire Extinguishers training back on the orientation training schedule for employees that are hired as remote workers indicating that the Fire Extinguisher training is a required training regardless of remote or on-site work details.
Monitoring: Ongoing
The Quality Assurance Manager will audit completion of required training prior to day 10 of orientation.
Hiring supervisors must review, confirm, and sign off that all required training courses have been met according to required timelines.
Site Directors will present required training courses compliance updates during quarterly reports.
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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, are trained to perform assigned tasks during emergencies in one of two applicable personnel records reviewed.
Employee # 6 was hired as a counselor on June 2, 2025. There was documentation in the personnel record indicating the emergency preparedness training was not completed until
August 1, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with standard 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.
Following the site visit, a meeting was held with the Site's Leadership Team along to discuss the findings of the audit. Standard 705.28 (d)(3) was reviewed with the Site's Leadership Team to ensure that everyone was clear on the requirements of the standard, acknowledging our failure to meet the standard, and agreed as to how failure to meet standard 705.28 (d)(3) will be avoided moving forward.
The Director of Training and Development was instructed by the CBHO to place the Fire Safety training back on the orientation training schedule for employees that are hired as remote workers indicating that Fire Safety training is a required training regardless of remote or on-site work details.
Monitoring: Ongoing
The Quality Assurance Manager will audit completion of required training prior to day 10 of orientation.
Hiring supervisors must review, confirm, and sign off that all required training courses have been met according to required timelines.
Site Directors will present required training course compliance updates during quarterly reports.
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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 a review of the facility's July 2024 through July 2025 fire drill logs, the facility failed to maintain a complete written fire drill record, which is to include the documentation of the exit route used during the drill.
The logs for the fire drills conducted on May 19, 2025 and July 12, 2024 did not include the documentation of which exit route was used for each drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address the non-compliance of standard 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.
Following the site visit, a meeting was held with the Site's Leadership Team along with the Lead Safety and Security Officer to discuss the findings of the audit. Standard 705.28 (d)(2) was reviewed with the Site's Leadership Team and Lead Safety and Security Officer to ensure that everyone was clear on the requirements of the standard, acknowledging our failure to meet the standard, and agreed as to how failure to meet standard 705.28 (d)(2) will be avoided moving forward.
According to the agency's policy in accordance with standard 705.28 (d) (2), fire drills are to be documented including the following information: the date, time, amount of time it took for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. Additionally, the fire drill form supports the written recording of all required elements.
To avoid any future infractions of 705.28(d)(4), the Site Director must thoroughly review prior to signing off on the fire drill documentation within one business day of the performed fire drill. Failure to fully complete the fire drill form will result in a repeat of the fire drill.
The QA Department will complete a targeted audit of Fire Drills monthly upon notification that a fire drill has been completed to ensure that 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 have been documented clearly on the fire drill form, filed in the site fire safety binder, and uploaded in the electronic site fire safety binder.
The QA Dept. will present the findings immediately to the Chief Behavioral Healthcare Officer. In the event, the audit findings fail to meet any regulatory standards that fall under Fire Safety 705.28, the Site Director and Safety/Security Officer will have less than 24 hours to complete a Fire Drill that meets all standards outlined in 705.28.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven client records reviewed.
Client # 2 was admitted on April 22, 2025 and was active at the time of inspection. A treatment plan update was completed on May 29, 2025 and the next update was due no later than July 29, 2025; however, the update was not completed at the time of inspection.
Client # 3 was admitted on April 1, 2025 and was active at the time of inspection. A treatment plan update was completed on May 29, 2025 and the next update was due no later than July 29, 2025; however, the update was not completed at the time of inspection.
Client # 7 was admitted on October 10, 2024 and was discharged on February 27, 2025. The comprehensive treatment plan was completed on October 10, 2024 and the first update was due no later than December 10, 2024; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with Standard 709.92(b) Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
Clinical Supervisors will monitor the DA Compliance Tracker weekly to identify Members with Treatment and Rehabilitation Plans that are approaching the 60-day review date and coordinate the due date in advance with the Counselor and Member.
Treatment and Rehabilitation Plans for Drug and Alcohol members are no longer driven by regularly scheduled appointments but developed and processed based on the treatment and rehabilitation plan update due date. All efforts will be made to coordinate with the members in advance to obtain collaborative input and signatures.
Treatment and Rehabilitation Updates will be finalized electronically every 60-days providing day 60 falls on a workday. In the event of day 60 falling outside of a scheduled workday, the Treatment and Rehabilitation Plan will be finalized within 24 hours of the scheduled Treatment and Rehabilitation Plan Update due date.
An addendum to information in the Treatment and Rehabilitation Plans may occur after the finalized Treatment and Rehabilitation Plan Update at the request of the Member, Counselor, or Clinical Supervisory Team. However, to maintain the veracity of the Treatment and Rehabilitation Plan Update original completion date, the addendum must be submitted as a New Treatment and Rehabilitation Plan Update.
The Counselors and Supervisors will be trained on Treatment and Rehabilitation Plan Update selection process on Wednesday, September 24, 2025.
On-going Monitoring:
The Counselors are responsible for routing Treatment and Rehabilitation Plans for review and approval. Supervisors must ensure that all signees have reviewed Treatment and Rehabilitation Plans in a timely manner to avoid finalization delays.
Supervisors will monitor treatment and rehabilitation plans weekly using the DA tracker to identify upcoming Treatment and Rehabilitation Plans that are due for a 60-day Update until the member has satisfied the requirements for program discharge.
The QA Department will continue to reconcile the treatment and rehabilitation plan audits weekly to identify treatment plan update completion and those in need of completion.
The Site Director will be responsible for weekly monitoring of the Clinical Supervisors compliance with tracking DA services and to ensure that quality services are being provided based on the level of care and treatment outlined in the treatment and rehabilitation plan.
The QA Manager will audit treatment and rehabilitation plans for compliance with 709.92 (b) and for clinical soundness. Aggregate findings per location, per supervisor, per counselor will be reported to the BH Leadership Team Monthly and Quarterly to the Executive Staff.
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