INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, We Care BH 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 personnel records, the facility failed to ensure a written individual training plan was developed for each employee, with input from both the employee and the supervisor, in one of one applicable personnel record reviewed.
Employee # 1 was hired as the project director/facility director on January 30, 2025. There was no individual training plan for the current year, documented in the personnel record 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 training management system such as
Relias, Medtrainer, or Psych Hub, etc. is being researched to be implemented for annual trainings for staff in compliance with accreditation regulations. A platform will be
chosen and implemented by 10/24/25.
*A training plan has been created and is
attached which will be completed with all current staff by 5/16/25 and within 30 days of hire for new staff. All new staff will be required to identify at least 3 trainings per year in the
training system to complete for their benefit.
*PD/FD will monitor progress on completion of trainings (both upon hire and annually) of all staff on a monthly basis. Automatic emails will be sent to all staff identifying upcoming trainings that are due along with overdue trainings from training management system once implemented. |
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 personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in one of one personnel record reviewed.
Employee # 1 was hired as the project director and facility director on January 30, 2025. There was no fire extinguisher training documentation at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*Annual Fire Safety trainings will be added to the training management system once implemented by 10/24/25.
*A Fire Safety Training was created and
implemented for all current and new staff until the training management system begins.
The training will be completed by current staff by 5/16/25. All new hires will complete the training within 30 days of start date.
*PD/FD will monitor progress on completion of trainings (both upon hire and annually) of all staff on a monthly basis. Automatic emails will be sent to all staff identifying upcoming trainings that are due along with overdue
trainings from training management system once implemented. |
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 facility's June 2024 through January 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there were no monthly fire drills conducted and documented during the entire reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*A monthly fire drill log created will identify unannounced versus unannounced drills, sounded versus unsounded alarm, the route used to evacuate, who participated in the drill, the location of the fire, the time to complete, problems identified during drill, resolutions,
follow up by safety officer, and signatures of staff and clients present during drill.
*The new fire drill log will be implemented for
May 2025 and forward. |
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 the project director and facility director on January 30, 2025. There was no documentation indicating the employee received a training to perform assigned tasks during emergencies in the personnel record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
*Annual Fire Safety trainings will be added to the training management system once implemented by 10/24/25.
*A Fire Safety Training was created and
implemented for all current and new staff until the training management system begins.
The training will be completed by current staff by 5/16/25. All new hires will complete the training within 30 days of start date.
*PD/FD will monitor progress on completion of trainings (both upon hire and annually) of all staff on a monthly basis. Automatic emails will be sent to all staff identifying upcoming trainings that are due along with overdue
trainings from training management system once implemented. |