INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Herkey Horizons 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:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and review of the personnel records, the facility failed to ensure that a written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
Employee #1 was hired on January 7, 2026 as the Project Director and was still in the position as of the date of the inspection. The training was completed on August 31, 2026.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Herkey Horizons LLC will ensure that a written individual training plan, appropriate to each employee's skill level, is developed annually with input from both the employee and the supervisor. Employee #1 (Project Director) was hired on January 7, 2026 and remains in that position as of the date of this POC submission. As noted in the finding, Employee #1's training was completed on August 31, 2026, before the September 8, 2026 inspection. On September 21, 2026, Employee #1 and the supervisor signed and dated Employee #1's written individual training plan for the September 1, 2026 to August 31, 2027 plan year, and the plan was placed in Employee #1's personnel file. The Executive Director then reviewed the personnel files of all current employees and confirmed that each has a current signed individual training plan or, for any employee hired within the past 30 days, is within the 30 day timeframe for completing one. To prevent recurrence, the individual training plan has been added to the new hire orientation checklist and must be completed within 30 days of hire. All plans are renewed each September at the start of the plan year with input from both the employee and the supervisor. The Executive Director maintains a tracking log of each employee's hire date and plan due dates and reviews it on the first business day of each month to confirm all plans are current. The Executive Director is responsible for ensuring these corrective actions are implemented and maintained. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on physical plant inspection, the facility failed to maintain a minimum of two exits on every floor that are separated by a minimum distance of 15 feet. The first floor only had one designated exit.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Herkey Horizons LLC will maintain a minimum of two exits on every floor, separated by a minimum of 15 feet. The first floor has two designated exits: the front entrance door and the emergency exit at the back end of the 1st floor which is the exit approved at the facility's initial licensure approval. The two exits exceed the 15 foot minimum. The ladder attached outside the window is not being used. On 9/21/26 an EXIT sign was installed at the emergency exit, the path to it was cleared and is kept unobstructed, and the door opens from the inside without a key, tool, or special knowledge. The revised first floor evacuation plan showing both exits was posted on the first floor and submitted to the Department's licensing specialist, who confirmed it is acceptable. All current staff were trained on both exits and the evacuation routes on September 21, 2026, documented in each personnel file. To prevent recurrence, the General Safety and Emergency Procedures policy was revised on September 21, 2026 to list the designated exits on each floor and to require a documented monthly exit inspection. The Executive Director inspects the exits on the first business day of each month and verifies the exit routes during each monthly unannounced fire drill. The Executive Director is responsible for ensuring these corrective actions are implemented and maintained. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #1 was hired on January 7, 2026 as the Project Director and was still in the position as of the date of the inspection. The training was completed on August 31, 2026.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Herkey Horizons LLC will instruct staff in the use of the fire extinguisher upon employment and will document that instruction. Employee #1, the Project Director, completed fire extinguisher training on August 31, 2026, before the September 8, 2026 inspection, and documentation of the training is maintained in Employee #1's personnel file. Employee #1 remains employed as of the date of this Plan of Correction submission. On September 21, 2026, all current staff received fire extinguisher instruction, documented with the training date, trainer, and employee signature. The Executive Director verified that documentation of the training is maintained in each current employee's personnel file.
To prevent recurrence, fire extinguisher instruction has been added to the new-hire orientation checklist. Fire extinguisher training will be assigned at the time of hire and completed within seven (7) days of the employee's date of hire. The employee's hire date and seven-day training due date will be documented on the new-hire orientation checklist. The Executive Director or designated Compliance Officer will review the new employee's orientation checklist and personnel file no later than the fifth day following hire to verify that the fire extinguisher training has been completed and documented. If the training has not been completed by the fifth-day review, the employee will be immediately scheduled to complete the training before the end of the seventh day of employment. Completion of the training will be verified and documented in the employee's personnel file.The Executive Director is responsible for ensuring that these corrective actions are implemented and maintained. |
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 fire drill logs from January, 2026 - August, 2026, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of fire drills occurring during the months of January, 2026- July, 2026.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Herkey Horizons LLC will conduct unannounced fire drills at least once a month. The drills missed from January 2026 through July 2026 cannot be conducted retroactively. On September 21, 2026, the Executive Director created a written 12 month fire drill schedule that assigns each month's drill a specific date and time, rotating days of the week and morning, afternoon, and evening sessions so that all staff on all shifts participate. The schedule is kept confidential by the Executive Director and is not shared with staff. The September 2026 unannounced fire drill was conducted on September 21, 2026 and recorded in the fire drill log, including the date, time, session, exits used, evacuation time, participants, and any problems noted. The Executive Director reviewed and signed the log the same day. Each drill is recorded the same day, and the Executive Director reviews and signs each log within 5 days. On the last business day of each month, the Executive Director verifies that the drill was completed and logged. If a drill cannot be held on its scheduled date, the Executive Director conducts it on another unannounced day before the month ends. The Executive Director is responsible for ensuring these corrective actions are implemented and maintained. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #1 was hired on January 7, 2026 as the Project Director and was still in the position as of the date of the inspection. The training was completed on August 31, 2026.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Herkey Horizons LLC will ensure that all personnel on all shifts are trained to perform their assigned tasks during emergencies within seven (7) days of hire and that completion of the training is documented in the employee's personnel file. Employee #1, the Project Director, completed training on assigned tasks during emergencies on August 31, 2026, before the September 8, 2026 inspection, and documentation of the training is maintained in Employee #1's personnel file. Employee #1 remains employed as of the date of this Plan of Correction submission. On September 21, 2026, the Executive Director updated the written emergency procedures to define staff responsibilities during a fire or evacuation, medical emergency including suspected overdose, severe weather, threatening person, and bomb threat. All current personnel on all shifts were trained on the updated procedures and their assigned emergency tasks. Completion of the training was documented on a signed training roster and in each employee's personnel file.
To prevent recurrence, emergency task training has been added to the new-hire orientation checklist. At the time of hire, the employee's hire date and seven-day training due date will be documented on the checklist. The required emergency task training will be assigned during orientation and completed within seven (7) days of the employee's date of hire. The Executive Director or designated Compliance Officer will review the new employee's orientation checklist and personnel file no later than the fifth day following hire to verify that the required emergency task training has been completed and documented. If the training has not been completed by the fifth-day review, the employee will be immediately scheduled to complete the training before the end of the seventh day of employment. Completion of the training will then be verified and documented in the employee's personnel file. All staff will also receive additional emergency-task training whenever emergency procedures or assigned responsibilities change.
The Executive Director is responsible for ensuring that these corrective actions are implemented and maintained. |