INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family Service Association of Bucks County 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 personnel records, the facility failed to ensure a written individual training plan was developed annually for each employee, with input from both the employee and the supervisor, in one of one personnel records reviewed.
Employee # 1 was hired as a project/facility director on November 20, 2024. There was no documentation indicating the individual training plan for the current 2024-2025 training year was completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new individual training plan form was created and will be added to each staff chart for the year. Associate Director of Clinical Services will ensure that new plan is completed for each employee and submitted to HR file. |
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, conducted at approximately 12:00 pm, the facility failed to ensure stairways, hallways, and exits from rooms and from the nonresidential facility were unobstructed.
At the time of the inspection, the side fire exit, from the facility, was obstructed by a ladder, boxes, computer equipment, and other various other objects.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire exit was cleared for all obstructions by Facilities Maintenance Manager. In addition, maintenance staff was informed that all materials must be cleared at all times to avoid obstruction of fire exits.
Facility Maintenance Manager will check all exits weekly to ensure there are no obstructions. |
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 personnel records, the facility failed to ensure all personnel, on all shifts, were trained to perform assigned tasks during emergencies in one of one personnel record reviewed.
Employee # 1 was hired as a project/facility director on November 20, 2024. There was documentation, in the personnel record, indicating the emergency preparedness training was not completed until June 26, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency preparedness training will be completed for all new employees at Quakertown location. In addition, any current FSA staff that begin working at Quakertown office will retake emergency preparedness training for Quakertown location immediately.
Associate Director of Clinical Services and Quality Improvement and Training Specialist will ensure all staff receive correct trainings at onboarding. |
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 November 2024 through June 2025 fire drill logs, the facility failed to document, on their written fire drill log, whether the fire alarm or smoke detector was operative during a drill.
The fire drill logs from January 2025, March 2025, April 2025, May 2025, and June 2025 did not include documentation of whether the fire alarm or smoke detector was operating at the time of the fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Five smoke and CO2 detectors were placed in Quakertown location on 8/19/25 by Facilities Maintenance Manager. All will be checked and noted on monthly fire drills. This will be conducted monthly by the Facilities Maintenance Manager. Photos/videos of the placement are available if needed. |