INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection conducted on July 8, 2025 through July 9, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Horizon House, 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an administrative review, the facility failed to present, to the Department Licensing Representative, a completed plan documenting the qualifications and training of all the project's staff at the time of the project's site visit.
At the time of the inspection, facility staff were unable to provide a completed and accurate Staffing Requirements Facility Summary Report to the Licensing Representative after multiple requests and attempts to provide technical assistance.
This is a repeat citation from the October 23, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Staffing Requirements Facility Summary has been brought up to date on August 14th, by Program Admin and QI Manager during their QI meeting. This document will be maintained by the Program Admin in real time. This report will be reviewed during the biweekly in-person QI meeting with QI Manager.
Program Management will ensure that this report is current and ready for DDAP submission at least 2 weeks prior to their licensing visit, and that the Cover Sheet is signed and dated by the Program Director.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the grounds of the facility were clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
At the time of the inspection, conducted on July 9, 2025, there was a water leak from the ceiling of the first floor TV room and hallway. There was also a documented June 29, 2025 incident involving a client due to water damage in the dining room. The facility failed to contact a roofing company until after this July 9, 2025 follow-up inspection. Additionally, there was a ceiling light panel, in the dining room, that was loose and not secured in the ceiling. It appeared the facility attempted to fix the light panel utilizing scotch tape.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The residential site checklist will continue to be completed on a daily basis. Program Manager will review this checklist upon completion and if areas of concern or maintenance needs are indicated, program management will submit a work order to real estate, or make other accommodations/arrangements needed to resolve the concern. Program Manager will followup on the work orders weekly until completed. This will be documented on a printed copy of the work order and kept in a separate binder with the Program Admin. Program Manager will provide updates on any outstanding work orders or concerns to the Regional Director during biweekly supervisions |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers 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 two of two applicable personnel records reviewed.
Employee #5 was hired as a counselor on August 5, 2024. There was no documentation the fire extinguisher training was provided as of the date of the inspection.
Employee #19 was hired as an administrative assistant on December 2, 2024. There was no documentation the fire extinguisher training was provided as of the date of the inspection.
This is a repeat citation from the October 23, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All residential staff will be trained/retrained on the use of the Fire Extinguisher and Residential Fire Safety by August 22, 2025. This will be evident by the staff member and program manager both initialing on the Residential Fire Safety Checklist, which will be stored in the Staff's training file, and indicated on the Staff Training Quantitative. Program Manager will update Regional Director of progress on 8/20/2025. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 two applicable personnel records reviewed.
Employee #5 was hired as a counselor on August 5, 2024. There was no documentation the emergency preparedness training was to the employee as of the date of the inspection.
Employee #19 was hired as an administrative assistant on December 2, 2024. There was no documentation the emergency preparedness training was to the employee as of the date of the inspection.
This is a repeat citation from the October 23, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained on Disaster Preparation and Response Training by August 20th. Staff will complete an attestation and a sign-off at the completion of the training. The date of completion is 8/20/2025.
Program Management and QI will be working together to monitor the ongoing training needs for the staff. The program admin is tracking and monitoring all trainings and during monthly QI Meetings, will share all completed trainings during that month. Program Management and Clinical Supervisor will also be reviewing training information during their ongoing supervisions with staff. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure annual written individual staff performance evaluations were completed, reviewed, and signed by the employee in two of two applicable personnel records reviewed.
Employee #2 was hired as the facility director on October 7, 2023. There was no annual written individual staff performance evaluation for the previous year documented in the record as of the date of the inspection.
Employee #3 was hired as a counselor on April 11, 2022. There was no annual written individual staff performance evaluation for the previous year documented in the record as of the date of the inspection.
This is a repeat citation from the October 23, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will be using our updated HR system to complete the annual staffing evaluations by August 30, 2025. The Regional Director will review the progress with the program manager by 8/22/2025 and again by 8/29/2025 Regional Director will provide progress update to QI, Division Director, and OQC Director. QI will indicate the completion on the Staff Training Quantitative to continue to monitor and provide feedback to Program Leadership as available. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system which allowed for the identification of clients' admission dates and discharge dates within a specific time period.
At the time of the inspection, the facility was unable to produce a complete discharge client list, upon request. It took facility staff approximately three hours to generate a complete and accurate discharge client list, with both admit and discharge dates.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
QI Director has provided a training document to the Program Manager and Program Admin to allow them to run the active participant list as well as the discharge participant list within the Electronic Health Record. This training document has been provided on 8/25/2025. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on review of the unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility involving the physical or sexual assault by staff or a client.
There was a reportable incident, which occurred on March 12, 2025, of a physical assault between clients; however, the incident was not reported to the Department as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All Susquehanna Park staff will receive training on the Incident Management Process on August 20th. Regional Director will work with Program Manager to ensure they have regained their DDAP Incident Portal Access by 8/15/2025. This will allow the access to accomplish the reporting requirements. During the interim, the staff will be submitting their incident reports by fax. The performance plan for Susquehanna Park includes this measure for ongoing review. The performance plan will be reviewed during ongoing QI meetings |