INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframes in one of one applicable personnel record reviewed.
Employee #6 was hired as a counselor on August 5, 2024 and was due to receive the HIV/AIDS training and the TB/STD training no later than August 5, 2025. There was no documentation in the personnel record indicating the HIV/AIDS training was completed 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
Upon hire, all staff will review and be provided the mandated DDAP trainings, the time frames for completion, and the website they are to review and sign up for these necessary trainings. This information will be documented as an addendum to their On-Site Residential Training and signed by each staff member as an acknowledgement of the expectation. All DDAP required trainings will be included on each staff's training plan, with the appropriate due date for completion.
If staff have been unable to register for a training because it is at capacity, the staff will screenshot the registration and provide to Administrative Assistant, to verify they are attempting to schedule. They will continue to monitor for the next available training. During their monthly supervisions, their training plan will be reviewed to ensure that all required trainings are completed within the expected time frame.
All attempts of scheduling should be clearly documented within their supervision documentation and barriers to scheduling will be addressed. |
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 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, there was an active water leak from the skylight located in the bedroom hallway on the third floor.
This is a repeat citation from the July 9, 2025 plan of correction follow-up inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
House Manager will complete the Residential Site Checklist a minimum of monthly. House Manager will complete the checklist during significant rain storms, as well, to monitor any possible roof leaks. Upon completion of the checklist, it will be submitted to the Program Director and work orders will be completed immediately. QI will review the monthly site checklists during their meetings with program leadership to ensure items identified have work orders completed and that follow-up is being completed timely.
Work orders will be monitored by Program Director weekly, with documented follow-up to the Real Estate Department related to status updates on outstanding items.
The current leak identified had a workorder submitted to our internal department, RED on October 30, 2025. On 12/4 the roofing company completed the repairs by adding tape and muck to the area of the leak. Our RED Department confirmed the repair has been completed. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of seven client records reviewed.
Client #1 was admitted on September 12, 2025 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on September 12, 2025; however, there was no name of the person, agency or organization to whom the disclosure was to be made documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A documentation training for completing Releases and Requests of information was held on Wednesday, November 12, 2025. The training focused on the completion of the release in entirety when on paper. This included clearly documenting the person, agency, or organization with address and phone number for the disclosure of information.
The staff are encouraged to complete all of the needed releases and requests for information within the Electronic Health Record to eliminate missing fields. Staff were instructed to ensure that all information is accurate and complete prior to having the participant signing the document.
At the next staff meeting program manager will review the Disclosure Checklist with all staff to assist in verifying all information has been completed prior to sharing information with any person or entity requesting the information.
QI will complete monthly chart reviews, during which they will review releases and requests of information and provide feedback to the program manager during this time. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in one of seven client records reviewed.
Client #1 was admitted on September 12, 2025 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on September 12, 2025; however, there was no specific information to be disclosed documented on the release form. Additionally, there were release of information forms to a pharmacy and a urinalysis laboratory signed and dated by the client on September 12, 2025; however, there was no specific information to be disclosed documented on both release forms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A documentation training for completing Releases and Requests of information was held on Wednesday, November 12, 2025. The training focused on the completion of the release in entirety when on paper. This included clarifying and documenting the information the participant is comfortable with being released or requested.
The staff are encouraged to complete all of the needed releases and requests for information within the Electronic Health Record to eliminate missing fields. Staff were instructed to ensure that all information is accurate and complete prior to having the participant signing the document.
At the next staff meeting program manager will review the Disclosure Checklist with all staff to assist in verifying all information has been completed prior to sharing information with any person or entity requesting the information.
QI will complete monthly chart reviews, reviewing releases and requests of information and provide feedback to the program manager during this time. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on release of information forms in one of seven client records reviewed.
Client #1 was admitted on September 12, 2025 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on September 12, 2025; however, there was no purpose of the disclosure documented on the release form. Additionally, there were release of information forms to a pharmacy and a urinalysis laboratory signed and dated by the client on September 12, 2025; however, there was no purpose of the disclosure documented on both release forms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A documentation training for completing Releases and Requests of information was held on Wednesday, November 12, 2025. The training focused on the completion of the release in entirety when on paper. This included the completion of the purpose for the release or request of information.
The staff are encouraged to complete all of the needed releases and requests for information within the Electronic Health Record to eliminate missing fields. Staff were instructed to ensure that all information is accurate and complete prior to having the participant signing the document.
At the next staff meeting program manager will review the Disclosure Checklist with all staff to assist in verifying all information has been completed prior to sharing information with any person or entity requesting the information.
QI will complete monthly chart reviews, reviewing releases and requests of information and provide feedback to the program manager during this time. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure and document whether a copy of a client consent to release information form was offered to the client in one of seven client records reviewed.
Client #5 was admitted on September 12, 2025 and was discharged on October 6, 2025. A release of information form to a treatment provider was signed and dated by the client on October 6, 2025; however, there was no documentation in the record indicating a copy of the release form was offered to the client. Additionally, a release of information form to another treatment provider was signed and dated by the client on October 20, 2025; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A documentation training for completing Releases and Requests of information was held on Wednesday, November 12, 2025. The training focused on the completion of the release in entirety when on paper. This included documenting that the participant accepted or declined a copy of the completed release.
The staff are encouraged to complete all of the needed releases and requests for information within the Electronic Health Record to eliminate missing fields. Staff were instructed to ensure that all information is accurate and complete prior to having the participant signing the document.
At the next staff meeting program manager will review the Disclosure Checklist with all staff to assist in verifying all information has been completed prior to sharing information with any person or entity requesting the information.
QI will complete monthly chart reviews, reviewing releases and requests of information and provide feedback to the program manager during this time. |