INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on May 5-7, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site investigation, James A Casey House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
The facility failed to maintain the facility in a clean, safe, sanitary and in good repair at all times as evidenced by a physical plant inspection on May 5, 2026 during a complaint investigation.Apartment 5 was observed to be missing an outlet cover in the living room.Apartment 12 was observed to have a broken kitchen chair and broken floor tiles in the living room.The Dayroom was observed to have two torn black chairs.
|
Plan of Correction
To correct the issue cited under 705.2(2) Building exterior and grounds, the missing outlet cover in Apartment 5 was replaced on 05/06/2026. The damaged chairs identified during the inspection were initially removed from use and replaced. During removal, damaged chairs that had been placed outside for disposal were taken back upstairs by a client. Moving forward, damaged furniture awaiting disposal will be secured in the basement or another staff-controlled area until final disposal so it cannot be returned to client-use areas. The broken floor tiles identified in Apartment 12 were repaired/replaced on 05/19/2026. The facility will strengthen physical plant inspections by completing more detailed reviews of apartments, common areas, dayroom furniture, outlet covers, flooring, and other safety-related concerns. Any missing outlet covers, damaged furniture, broken flooring, or other hazards will be reported, documented, and followed through the maintenance process until corrected. Maintenance staff and supervisory staff will monitor these areas, with oversight by the Project Director.
|
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.
|
Observations
The facility failed to maintain living room furnishings in a state of good repair as evidenced by a physical plant inspection on May 5, 2026 during a complaint investigation.Apartment 3 was observed to have a brown torn couch in the living room.Apartment 4 was observed to have a torn black chair in the kitchen/living room area.Apartment 6 was observed to have a brown chair in the living room with cigarette burns all over. Apartment 7 was observed to have a flowered couch which was torn and the stuffing was coming out through the bottom of the couch in the living room.Apartment 9 was observed to have a torn and stained gray couch in the living room.
|
Plan of Correction
To correct the issue cited under 705.3 Living rooms and lounges, which requires furnishings to be maintained in good repair, the torn black chair in Apartment 4 and the brown chair with cigarette burns in Apartment 6 were removed and replaced on 05/05/2026. The damaged couches in Apartment 3 and Apartment 9 were covered to reduce further exposure of the damaged areas while replacement is being completed. The facility is actively replacing the damaged couches identified in Apartment 3, Apartment 7, and Apartment 9, with planned completion by 06/15/2026. Active room checks will include detailed furniture reviews of couches, chairs, tears, stains, cigarette burns, exposed stuffing, and any other signs that furniture is no longer in good repair. Furniture concerns will be reported, documented, and followed until corrected, removed, or replaced. Supervisory staff and maintenance staff will monitor furniture conditions and corrective actions, with oversight by the Project Director.
|
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as evidenced by:During a physical plant inspection conducted on May 5, 2026 as part of a complaint investigation, a counseling session occurred in a glass room inside the shared the counselors' office which could be heard and seen outside of the glass counseling room.During a complaint investigation on May 6, 2026, an intake counseling session occurred in the intake office which is a glass room inside the security camera surveillance room which could be seen and heard outside of the intake office/counseling room.
|
Plan of Correction
To correct the issue cited under 705.4(3) Counseling areas, which requires counseling sessions to be private and not seen or heard outside the counseling room, the Project Director conducted in-house training with counseling and intake staff on 05/06/2026. Staff were trained on proper room setup, how to determine if a room is appropriate before starting an individual or intake session, and how to protect both visual and sound privacy. When the counseling office or the room near the surveillance area is used, blinds will remain closed, doors will remain closed, and staff will monitor voice level and room setup. If privacy cannot be maintained in either space, staff will use one of the two other available private session areas. The facility addressed the privacy concern immediately and ordered four sound devices to further support sound privacy, with expected delivery on 05/29/2026. The four sound devices will be placed in all three counseling session rooms and one intake room. Counseling and intake staff will be responsible for selecting an appropriate private area before each session. The Lead Counselor will monitor compliance with counseling-area privacy expectations, with oversight by the Project Director. |
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.
|
Observations
The facility failed to ensure that each resident have a bed with foundation and mattress in good repair as evidenced by a plant physical inspection on May 5, 2026 during a complaint investigation.Apartment 6 was observed to have a stained mattress/box spring in bedroom 3.Apartment 7 was observed to have a stained mattress/box spring in bedroom 1. Apartment 10 was observed to have a torn mattress/box spring in bedroom 2.
|
Plan of Correction
To correct the issue cited under 705.5(a)(1) Sleeping accommodations, which requires each resident to have a bed with a solid foundation and fire-retardant mattress in good repair. the stained mattress/box spring in Apartment 6, Bedroom 3, the stained mattress/box spring in Apartment 7, Bedroom 1, and the torn mattress/box spring in Apartment 10, Bedroom 2 were removed and replaced on 05/07/2026. Room inspections will now include a more detailed review of beds, mattresses, box springs, foundations, stains, tears, and any other condition showing bedding is no longer in good repair. Bedding concerns will be reported, documented, and followed until corrected, removed, or replaced. Maintenance staff and supervisory staff will monitor bedding conditions during routine inspections, with oversight by the Project Director.
|
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
The facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times as evidenced by a plant physical inspection on May 5, 2026 during a complaint investigation.Apartment 3 was observed to have a bathroom with a black mold-like substance in and around the bathtub. Apartment 7 was observed to have a bathroom with black mold-like substance around the calking of the bathtub. Apartment 12 was observed to have a broken floor tiles in the bathroom.
|
Plan of Correction
To correct the issue cited under 705.6(7) Bathrooms, which requires each bathroom to be maintained in a functional, clean, and sanitary manner, the bathroom concerns in Apartment 3 and Apartment 7 were corrected on 05/06/2026, including cleaning and addressing the mold-like substance observed in and around the bathtub areas. The broken bathroom floor tiles in Apartment 12 were repaired/replaced on 05/19/2026. Bathroom inspections will include detailed review of tubs, caulking, floors, tile condition, mold-like buildup, cleanliness, sanitation, and overall bathroom function. During intake and orientation, clients will be reminded that they are responsible for maintaining assigned living areas, including bathroom cleanliness, as part of the facility's life skills expectations. Staff will remain responsible for monitoring bathroom conditions during routine inspections, including when rooms are occupied and when rooms become vacant. Bathroom concerns will be reported, documented, and followed until corrected. Maintenance staff and supervisory staff will monitor bathroom conditions and corrective actions, with oversight by the Project Director.
|
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
|
Observations
The facility failed to be free of rodent and insect infestation. Based on client and staff interviews along with a review of administrative and other documentation during a complaint investigation, there was evidence of rodent and insect infestations in the facility. 100 percent of the clients interviewed reported seeing mice in their apartments within the facility during the current month and previous months. In addition, documentation showed mice infestations in apartments 1 and 9 in January, apartment 1 in February, and apartment 10 in March.78 percent of the clients interviewed reported seeing bugs and/or receiving bug bites in their apartments within the facility within the current month and previous months. In addition, documentation showed that the following facility apartments had insect infestations: 9 and 2 in January, 1, 4, 8, 9, and 11 in April, 2 and 12 in March. In addition, the main building dayroom had insect infestations in March and April. Also, the main building basement has an insect infestation in March. Additionally, pictures and videos of bugs, and bug bites, along with medical documentation appeared to indicate the presence of bed bugs.
|
Plan of Correction
To correct the issue cited under 705.9(1) General safety and emergency procedures, which requires the residential facility to be free of rodent and insect infestation, the Project Director met with staff on 05/08/2026, 05/11/2026, and 05/12/2026 to review prevention, inspection, reporting, documentation, and follow-up related to mice and bed bug activity. Staff were instructed that signs of mice, bed bug activity, bites, droppings, nesting signs, bed bug casings, or related deficiencies must be documented, reported to maintenance and supervisory staff, and followed until corrective action is completed.
To help prevent recurrence, client bags and belongings will be inspected thoroughly upon admission before being brought into client living areas. If signs of bed bug activity are observed, clothing and appropriate belongings will be placed through the dryer in the basement laundry area before being brought into client living areas. Staff will also complete more detailed room checks and walkthroughs for conditions that may contribute to mice or bed bug activity, including food left out, trash buildup, clutter, droppings, nesting signs, cracks, gaps, and other related deficiencies. Clients will be reminded during intake, orientation, and ongoing program discussions that they are responsible for maintaining their assigned living areas, including food storage, trash removal, cleanliness, and prompt reporting of mice or bed bug concerns.
The facility has an exterminator who reports on site once per month for routine checkups related to mice and bed bug prevention. During routine monthly service, the exterminator checks applicable client living areas and common areas for signs of mice and bed bug activity. When deficiencies are identified, corrective action is taken as part of the same prevention and treatment process. This may include applying dust or spray treatment to bed frames, cracks, crevices, couch areas, and baseboards to help prevent recurrence and address observed activity.
If mice or bed bug-related deficiencies are reported between routine monthly visits, the exterminator will be contacted and scheduled as early as possible based on availability. Pending extermination services, the facility will use approved spray and powder treatment to assist with eradicating observed activity and reduce further spread. The facility will also take immediate action when appropriate, including cleaning the affected area and having client clothing and bedding placed through the dryer in the basement laundry area.
Mice and bed bug-related concerns, corrective actions, exterminator contact, routine exterminator visits, room checks, and follow-up will be documented and reviewed for completion. Maintenance staff and supervisory staff will monitor prevention efforts, corrective actions, and related documentation, with oversight by the Project Director.
|
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.
|
Observations
The facility failed to limit smoking to the designated smoking areas as evidenced by a plant physical inspection on May 5, 2026 conducted during a complaint investigation.Apartment 10 was observed to smell like clients had recently been smoking in it. Apartment 12 was observed to smell like clients had recently been smoking in it and cigarette ashes were observed on top of a Scrabble board game box in the living room.
|
Plan of Correction
To correct the issue cited under 705.9(3) General safety and emergency procedures, which requires the facility to limit smoking to designated smoking areas, clients were addressed on 05/08/2026, 05/09/2026, and 05/10/2026 regarding the facility's smoking expectations. Clients were reminded that smoking is limited to designated smoking areas only and is not permitted inside apartments, bedrooms, bathrooms, living rooms, or other non-designated areas. Multiple dates allowed the facility to review this expectation with clients across different schedules and ensure current clients were addressed regarding the smoking policy. The facility will strengthen its existing walkthrough and room inspection process by completing more detailed reviews for signs of smoking in client living areas, including smoke odor, ashes, cigarette remains, cigarette burns, lighters, and other evidence of smoking in non-designated areas. Managers will continue completing walkthroughs and monitoring for smoking-related concerns. Any smoking concern identified during walkthroughs or room inspections will be addressed with the client, documented as needed, and followed through according to facility expectations. Managers and supervisory staff will monitor compliance with designated smoking areas, with oversight by the Project Director.
|