INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28, 2022, 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on September 28, 2022, the facility failed to ventilate the bathroom with an exhaust fan or window.
The exhaust fan in the bathroom was not operable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program manager enlisted HVAC staff to add a fan, as was intended in its original installation. Work was completed 10/6/22 and fan is now fully functional. Program manager will check the fans functionality monthly to ensure it is working. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted on September 28, 2022, the facility failed to not permit heaters that are not permanently mounted or installed.
There was a space heater inside the door going toward the emergency exit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Heater was removed by Program Manager on 9/29/2022. Program Manager with staff that space heaters are not permitted and will brief incoming staff and contractors of this. Program Manager will inspect the facility monthly to ensure there are no space heaters. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on September 28, 2022, the facility failed to ensure that exits from rooms and from the nonresidential facility are unobstructed.
The door leading to the emergency exit was locked at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager directed staff to unlock the door leading to second emergency exit on 9/28/2022. Program Manager reviewed with staff at weekly meeting that this door must remain unlocked and will brief incoming staff and contractors of this requirement. Program Manager will inspect monthly to ensure compliance. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log submitted during the licensing process, the facility failed to conduct unannounced fire drills at least once a month. The facility was licensed in January 2022 and only one fire drill was documented between that time and the time of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager updated fire drill logs with all required elements for audit and noted monthly requirement to drill on 9/28/2022. Program Manager notified staff that this would occur and set calendar reminders to schedule monthly drills at random and unannounced times each month. |
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 written fire drill log, the facility failed to maintain a written fire drill record including 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.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager updated fire drill logs with all required elements for audit and noted monthly requirement to drill on 9/28/2022. Program Manager notified staff that this would occur and set calendar reminders to schedule monthly drills at random and unannounced times each month. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility ' s written fire drill log, the facility failed to document that a fire alarm or smoke detector was set off during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager updated fire drill logs with all required elements, including ensuring the smoke detector is set off, for audit and noted monthly requirement to drill on 9/28/2022. Program Manager notified staff that this would occur and set calendar reminders to schedule monthly drills at random and unannounced times each month. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to include policies and procedures for documentation of unusual incidents.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager updated the policy 10/12/2022 to correct the deficiency.
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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to include policies and procedures for the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager updated the policy 10/12/2022 to correct the deficiency. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to include policies and procedures for the implementation of a timely and appropriate corrective action plan, for unusual incidents when indicated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager updated the policy 10/12/2022 to correct the deficiency. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to include policies and procedures for the ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager updated the policy 10/12/2022 to correct the deficiency. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to include policies and procedures for having a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager updated the policy 10/12/2022 to correct the deficiency. |