INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and relocation physical plant inspection conducted on October 17, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gentle Force Counseling Services LLC, 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:
|
Plan of Correction
|
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
|
Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
At the time of the inspection, there were no operable hard-wired or battery-operated smoke detectors placed in the counseling suite, which is located within a shared office building.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will install automatic smoke detectors by 12/15/2025.
The facility director will ensure the smoke detector is functioning correctly on a continuous monthly basis.
The facility director will update the energy evacuation policy to include monthly detector checks and review the policy annually. |
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.
|
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 one of one applicable personnel record reviewed.
Employee # 1 was hired as the project director and facility director on February 1, 2021. There was no documentation in the personnel record showing any emergency preparedness training was completed for the facility's recent relocation address.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will develop and implement new training for all staff on assigned tasks during emergencies for the new location by 1/15/2026.
The facility director will ensure that all staff receive safety training and evacuation plans for the new site by 1/15/2026. Training will continue annually. Monthly emergency internal exit drills will continue.
The facility director will complete annual internal training hour verification to ensure all staff are trained. |