INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, James A. Casey House, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel files, the facility failed to ensure that one applicable lead counselor had completed a core curriculum in clinical supervision which is a requirement for the position.Employee # 2 was promoted to the position of lead counselor on January 1, 2024 and is current in that position. Employee # 2 did not complete a core curriculum as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and the Clinical Director will be responsible for verifying that all prospective staff member's meet the educational and experiential requirements for their position prior to being hired. The facility Policy and Procedure Manual's Compliance Plan regarding 704.2(a)&(b) will be utilized for all future prospective employees prior to actual date of hire.
Employee # 2 is no longer employed with the James A Casey House.
With the direction of the Project Director and Clinical Director, any employee that is promoted will have the necessary requirements per DDAP standards prior to the promotion. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of six personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.Employee # 6 was hired as a counselor assistant on April 4, 2023 prior to being promoted to the position of counselor on April 1, 2024. Employee # 6 had a high school diploma at the time of hire through March 2024, and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee # 6 did not receive documented direct supervision from June 14, 2023 - July 14, 2023 or documented close supervision from July 14, 2023 - April 2024. Direct observation is defined by regulation as follows: "In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities." In accordance with 28 Pa. Code 704.9(a), a counselor assistant must be supervised by a fulltime clinical supervisor or a full-time counselor. The fully qualified clinical supervisor or counselor is then responsible for weekly supervision notes relating to the counselor assistant. Clear documentation in the weekly notes and in the pertinent client charts must also demonstrate that direct observation is occurring.Close supervision is defined by regulation as follows: "Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week."Documented supervision did not identify that direct observation or formal case reviews were occurring in the dates noted above. This is a repeat citation from the June 21, 2023 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor assistants with a high school diploma or GED may counsel clients only under direct observation of a counselor or clinical supervisor for the first three months of employment. For the next nine months the counselor assistant may only counsel under the close supervision of a counselor or clinical supervisor. No later than 10/18/24, the clinical supervisor will conduct a training session, for all clinical and quality assurance staff, regarding Chapter 704 Staffing requirements for drug and alcohol treatment activities, specifically, 704.8 Qualifications for the position of counselor assistant, 704.9 Supervision of counselor assistant and 704.10 Promotion of counselor assistant. The project director will follow-up to ensure that clinical staff has received and understands this training. The quality assurance staff, through ongoing reviews of training documents, will ensure that counselor assistant training is properly documented in accordance with Chapter 704 Staffing requirements for drug and alcohol treatment activities. Employee #6 is currently enrolled in an associates degree program and is 2 semesters away from receiving his degree, he will continue to work under the close supervision of the clinical supervisor. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and CPR and first aid certifications provided by the facility, the facility failed to ensure that at least one person trained in CPR and first aid was onsite during the project's hours of operations. The 11:00 p.m. - 7:00 a.m. shifts between June 21, 2023 and May 1, 2024 did not have staff trained in CPR and first aid.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/1/24, 10 support staff members received CPR / First Aid training. This will ensure that trained staff members are available to cover all shifts at this time. These trainings are valid for 2 years. In the past, we have scheduled CPR training every two years. However, because of possible attrition, etc., we will also schedule an additional training in May of 2025 for ten additional staff, support and clinical. This will provide us with an abundance of CPR /First Aid trained staff. The Project Director will be responsible for ensuring that sufficient staff are available for CPR/First Aid coverage 24/7/365. The Project Director will ensure that future CPR/First Aid trainings are scheduled on a yearly basis during May of each calendar year, this should ensure that the majority of our staff, at any given time, will be qualified to perform CPR and First Aid. This will also ensure that any staff members lacking the "one and done" First Aid training will be able to fulfill that requirement. This plan has been discussed with the Governing Body, the Owner, and he agrees that this will ensure that we have plenty of qualified staff. |
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 a physical plant inspection conducted on July 30, 2024, the facility failed to keep the grounds clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The following was observed during the physical plant inspection: Apartment 12Bedroom 4 is missing floor tile in the closet.Apartment 9Bedroom 1 has cracked and missing floor tiles, and an area of discoloration and dust on the ceiling near the ventilation system. Bedroom 2 has cracked floor tiles.Kitchen has broken floor tiles.Bathroom has a cracked sink. Living room has broken floor tiles and damaged ceiling tiles, which have holes and missing pieces.Apartment 8Bedroom 2 has broken and cracked floor tiles and a sharp/cracked window stool/apron.Bedroom 3 has broken and cracked floor tiles.Apartment 6Bedroom 1 has an area of discoloration and dust on the ceiling near the ventilation system. Bedroom 3 has a damaged wall/dent in drywall.Bathroom has a thick layer of dust on the top of the window. Apartment 5Bathroom light is missing a light cover.Apartment 2Bedroom 4 has damaged and cracked floor tiles.Living room has peeling, missing, and damaged floor tiles in the rear left corner.Counselor OfficesA long heating element under the bay window did not have a protective covering.Stairwell between the first and second floors has some steps with worn/cracked/missing edges that are a tripping hazard.This is a repeat citation from the May 7, 2024 provisional license inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a facility maintenance plan, including developing an updated maintenance log, in order to report, track, and correct physical plant deficiencies. All facility areas will be inspected weekly by the Project Director and/or his designated representative. All deficiencies will be documented in the facility maintenance log. Any deficiencies regarding safety issues will be corrected immediately upon discovery. Following each weekly facility inspection, the maintenance log will be updated and new discrepancies will be reviewed by the Project Director and/or his representative facility maintenance staff. During this review any corrective actions taken by the maintenance staff during the week will be reviewed. The Project Director and/or his representative will perform a follow-up inspection on all corrective actions to ensure compliance with regulations. All of the inspection deficiencies have been entered in the facility maintenance log. Immediately following the complaint inspection all deficiencies identified with safety / tripping concerns were corrected, and signed off in the maintenance log. Many other deficiencies have been corrected and signed off by the maintenance staff. Items requiring repair or replacement, mattresses, furniture, etc., have been repaired or replaced. The remainder of the write-ups such as stair coverings, etc. are awaiting parts and will be corrected when they are received. Any currently open deficiencies will be corrected by November 15, 2024 or as soon as the required parts are received.
Apartment 12
Bedroom 4 - Missing floor tile replaced - 10/4/2024
Apartment 9
Bedroom 1 - Missing floor tile replaced dust removed - 10/3/2024
Bedroom 2 - Floor tiles replaced 10/4/2024
Kitchen - Floor tiles replaced - 9/30/2024
Bathroom sink has been repaired with epoxy - 9/20/2024
Living room floor tiles and ceiling have been replaced - 9-20-2024
Apartment 8
Bedroom 2 - replaced broken floor tiles and replaced cracked window - 9-20-2024
Bedroom 3 - replaced broken floor tiles - 9-20-2024
Apartment 6
Bedroom 1 - Dust has been removed from bedroom - 10-3-2024
Bedroom 3 - Drywall repaired, Dust removed - 9-20-2024
Apartment 5
Bathroom light cover replaced - 9-16-2024
Apartment 2
Bedroom 4 - Floor tile replaced - 10-3-2024
Counselor Office
Replaced heating element cover - 10-4-2024
Stairwell - Stair safety step covering are on order to prevent tripping hazard.
Estimated repair is 11-15-2024
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection conducted on July 30, 2024, the facility failed to maintain furnishing in a state of good repair in living rooms and lounges.The following was observed during the physical plant inspection conducted on July 30, 2024: Apartment 8 has a torn plaid loveseat and a stained gray chair with cigarette burns.Apartment 7 has a beige chair that is severely stained and with worn fabric. Apartment 4 has a burgundy sofa with multiple cigarette holes/burns.Apartment 1 has a plaid sofa and cigarette burns/holes.This is a repeat citation from the May 7, 2024 provisional license inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a facility maintenance plan, including developing an updated maintenance log, in order to report, track, and correct physical plant deficiencies. All facility areas, including lounges and living rooms, will be inspected weekly by the Project Director and/or his designated representative. All deficiencies will be documented in the facility maintenance log. Any deficiencies regarding safety issues will be corrected immediately upon discovery. Following each weekly facility inspection, the maintenance log will be updated, and new discrepancies will be reviewed by the Project Director and/or his representative and the maintenance staff. During this review any corrective actions taken by the maintenance staff between inspections will be discussed. The Project Director and/or his representative will perform a follow-up inspection on all corrective actions to ensure compliance with regulations. Any furniture in disrepair will be entered in the maintenance log and will be repaired or replaced by the facility maintenance staff as soon as possible. Regarding this complaint inspection, all identified damaged items of furniture have been replaced with clean, serviceable replacements. All of these deficiencies were entered in the maintenance log and signed off by the maintenance staff and a follow-up inspection to ensure compliance was performed by the Project Director or his designated representative.
Corrective actions were completed on 9/30/2024. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection conducted on July 30, 2024, the facility failed to supply a bed with solid foundation and a fire retardant mattress in good repair. The following was observed during the physical plant inspection:In apartment 1, bedroom 2 has a severely stained box spring.This is a repeat citation from the May 7, 2024 provisional license inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a facility maintenance plan, including an updated maintenance log, in order to report, track, and correct physical plant deficiencies. All facility areas, including mattresses, box springs, and bed frames, will be inspected weekly by the Project Director and/or his representative. All deficiencies will be entered in the facility maintenance log. Any discrepancies regarding safety issues will be corrected immediately upon discovery. Following each weekly facility inspection, the maintenance log will be updated and any new discrepancies will be reviewed by the Project Director and/or his representative and the maintenance staff. During this review any corrective actions taken by the maintenance staff during the prior week will be reviewed. The Project Director and/or his representative will perform a follow-up inspection on corrective actions taken by the maintenance staff during the prior week to ensure compliance with regulations.
All mattresses and box springs identified during the complaint inspection were entered in the maintenance log as unserviceable and they were removed and replaced immediately following the complaint inspection, due to safety issues such as sharp edges and severe stains, and signed off by the maintenance staff. The Project Director or and/or his representative have performed a follow-up to ensure compliance on September 30, 2024. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on July 30, 2024, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom or an operable soap dispenser in each bathroom. There were no operable soap dispensers in the bathrooms of Apartments 11, 8, 6, 5, 4, and 3. There were no paper towels or mechanical dryers in the bathrooms of Apartments 8 and 6. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director consulted with the facility maintenance staff supervisor to determine a course of action to correct this deficiency. All paper towels have been replaced with staff replacing the paper towels daily.
All apartment bathrooms have now been supplied with soap containers for corrective action in the deficiency listing.
The Project Director and the staff supervisor will ensure that all apartment bathrooms are checked multiple times (8:00am, 12:00pm, 4:00pm, 8:00pm) daily and supplies refilled when needed. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conducted on July 30, 2024, the facility failed to limit smoking to designated smoking areas. During the physical plant inspection, the following was observed:Apartment 12 smelled like cigarette smoke.Apartment 9, Bedroom 2 smelled like cigarette smoke.This is a repeat citation from the May 7, 2024 provisional license inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director is responsible for ensuring smoking is limited to designated smoking areas. The facility has a large semi-covered area in the rear of the facility this is the designated smoking area. There is no smoking allowed inside the facility. For the most part, clients accept and abide by this policy. For those clients who have trouble following this policy, we have relied on apartment/room inspections and report by other clients/roommates. In order to get a better source of information on goings on in the apartments, the Project Director and the support staff supervisor have assigned blocks of three apartments each to one dayshift and one second shift support staff members. This means there are two staff members on two different shifts monitoring a block of three apartments. These staff members will be responsible for visiting each of their assigned apartments at least once a day. The idea is that we will not only learn which clients may be smoking, but we will have much more information on roommate relationships, who is not doing his fair share of cleaning, who is taking other room mates food etc. The clients in apartment 12 and apartment 9 bedroom 2, received a verbal warning as a first offense. Our policy on clients smoking inside are first offense verbal warning, second offense written warning, third offense behavioral contract / case consultation, fourth offense possible discharge. Because we are starting this apartment monitoring policy as of 9/1/2024 we can expect it to be fully implemented by 10/15/2024. The Project Director and the staff support supervisor will be responsible for implementing and oversight of this policy. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to document that an annual report for 2023 included a statement with the names of officers, directors and principal shareholders. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall ensure that the facility annual report for the prior year is posted on the official facility website by no later than 31 January of the current year. The most recent annual report, for the calendar year 2023, will be posted on the facility website no later than 1 September 2024. Quality Assurance staff have been instructed to add the report to their December calendar and to remind the Project Director to post the annual report by 31 January of the upcoming year. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a discussion with facility staff, the facility failed to follow the exception granted to them for the annual financial audit. The facility did not ensure that the tax information was onsite and available for review during the onsite annual inspection or during the licensing process. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall ensure that the annual audit is available during annual DDAP inspections. Upon notification of future DDAP inspections, the Project Director will request a copy of the most recent audit from the facility owner and/or his accountants so that it will be available for review during the inspection. |
709.28 (c) 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.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information prior to disclosing information in one record reviewed. Client # 2 was admitted on August 15, 2023 and was discharged on November 8, 2023. The record contained documentation of a disclosure of information to an attorney on October 25, 2023, to whom the record contained no informed and voluntary consent to release information form signed by the client.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide a training session to clinical staff regarding documentation of disclosure and associated documentation no later than October 4, 2024. The Project Director will provide oversight to ensure compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five records reviewed.Client # 1 was admitted on February 19, 2024 and was discharged on April 25, 2024. The individual treatment and rehabilitation plan was completed on February 19, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client # 2 was admitted on August 15, 2023 and was discharged on November 8, 2023. The individual treatment and rehabilitation plan was completed on August 15, 2023; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.Client # 3 was admitted on April 23, 2024 and was discharged on June 3, 2024. The individual treatment and rehabilitation plan was completed on April 23, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client # 6 was admitted on May 7, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 7, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client # 7 was admitted on April 1, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 1, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and quality assurance staff are responsible for ensuring that all required clinical documentation meets regulations. At the weekly staff meeting on September 16, 2024, the clinical staff was counseled on the importance of proper documentation and the need add the frequency of treatment and rehabilitation services within the required timeframes. This will be repeated during subsequent staff meetings to ensure familiarization and conformity.
Quality assurance staff was directed to pay special attention to this area and to immediately report any deficiencies to the Clinical Director. Any counselors that are having difficulties with understanding the new treatment plan format will be identified by quality assurance and will receive individual instruction by the Clinical Director. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, including follow up information, in two of four applicable records.Client # 2 was admitted on August 15, 2023 and was discharged on November 8, 2023. The record did not contain documentation of follow-up information. Client # 4 was admitted on August 16, 2023 and was discharged on October 31, 2023. The record did not contain documentation of follow-up information. This is a repeat citation from the June 21, 2023 and August 3, 2022 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director shall ensure that here is at least one attempt to follow-up on all clients regardless of type of discharge. Quality Assurance staff will monitor all discharges to ensure that a follow-up is documented in all client charts. The Clinical Director will provide a training session to clinical staff regarding follow-ups and associated documentation no later than October 4, 2024. The Project Director will provide oversight to ensure compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing follow-up information was submitted and approved by the Department for the June 21, 2023 and August 3, 2022 annual licensing inspections. Failing to complete follow-up information was again found to be a deficiency in the July 30, 2024 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will continue to comply with all of the plans of correction that were approved by the Department.
The Project Director will be responsible for implementing new staff to ensure that all additional monitoring will take place in a timely manner. The Project Director will meet with the staff supervisor on a daily basis to communicate all directives needed.
The project Director will complete all corrections and follow-up information in a timely manner. |