INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2-3, 2025, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.Employee #5, who was hired as a counselor on June 9, 2025, did not meet the educational requirements to be a counselor. At the time of the onsite renewal, the facility did not have documentation to verify that the employee had completed the educational requirements for this position. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency cited under §704.7(b) was identified and reviewed on October 20, 2025. The issue occurred because one staff member's file did not contain final documentation verifying completion of the required educational qualifications for the counselor position. The Project Director confirmed that the individual has completed the necessary coursework and is in the process of obtaining official documentation from the educational institution. The Project Director and, when appropriate, the Clinical Supervisor are responsible for verifying and filing the documentation once received. Until the documentation is received and verified, the individual will continue to operate within Counselor Assistant qualifications in cooperation with DDAP standards. The Project Director will also conduct quarterly personnel file reviews to ensure continued compliance with §704.7(b). |
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 and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.Employee #7 was hired as a counselor assistant on February 1, 2024, and was due to have the communicable disease training no later than February 1, 2025. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection. Employee #9 was hired as a Lead Technician on May 28, 2023, and was due to have the communicable disease training no later than May 28, 2025. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #10 was hired as a Behavioral Technician on February 10, 2023, and was due to have the communicable disease training no later than February 10, 2025. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #11 was hired as a Behavioral Technician on September 11, 2023, and was due to have the communicable disease training no later than September 11, 2025. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection. Employee #12 was hired as a Behavioral Technician on January 2, 2023, and was due to have the communicable disease training no later than January 2, 2025. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection. Employee #13 was hired as a Behavioral Technician on February 10, 2023, and was due to have the communicable disease training no later than February 10, 2025. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection. Employee #14 was hired as a Behavioral Technician on October 25, 2013, and was due to have the communicable disease training no later than October 25 2015. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency cited under §704.11(c)(1) was addressed on October 20, 2025. The Project Director reviewed all personnel files identified in the inspection and confirmed that the affected employees have been scheduled to complete the required HIV/AIDS and TB/STD trainings through a Department-approved provider. Documentation of completion will be placed in each personnel file upon verification. Moving forward, the Project Director and, when appropriate, the Clinical Supervisor will maintain a staff training tracker to monitor due dates for all communicable disease trainings. The tracker will be reviewed monthly during supervision to ensure that all staff remain compliant within the required timeframes. The Project Director is responsible for oversight and ensuring continued compliance with §704.11(c)(1) |
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, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each facility bathroom. It was observed by DDAP staff that there were no paper towels in the apartment #10 bathroom and in the 1st floor bathroom near the counselor's office. This is a repeat citation from the July 30, 2024, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The missing paper towels cited under §705.6(2) were corrected on October 3, 2025. The Project Director verified that all bathrooms now have either individual paper towels or a mechanical dryer. Lead Behavior Technician will inspect all bathrooms weekly to confirm that paper towels are in place and will continue to discuss the importance of this standard at every staff meeting. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide slip-resistant surfaces in all bathtubs and showers.It was observed by DDAP staff that the shower in apartment #1 did not have any non-slip material.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The missing slip-resistant surfaces cited under §705.6(4) was corrected on October 6, 2025. The Project Director verified that all bathtubs and showers now have proper slip-resistant surfaces. Lead Behavior Technician will ensure said surfaces are replaced immediately if missing or damaged and will reinforce the importance of keeping these safety measures in place during staff meetings. |
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.
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Observations
Based on a physical plant inspection the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.It was observed by DDAP staff that the shower in apartment #10 had been painted over and that the paint was severely peeling.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The peeling paint in the bathroom cited under §705.6(7) was repaired and repainted on October 6, 2025. The Project Director verified that all bathrooms are clean, functional, and sanitary. The Lead Behavior Technician will inspect bathrooms weekly and immediately report any issues to maintenance. Staff were reminded that peeling paint or poor maintenance is unacceptable and must be corrected immediately upon discovery. Project director will be notified if such findings occurred. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training in the use of the fire extinguisher upon employment. Employee #6 was hired on May 19, 2025, for the position of counselor and was still employed in this position at the time of the inspection. There is no documentation in this employee's personnel record to verify this training was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility did not have documentation verifying that a counselor hired on May 19, 2025, received required training in the use of fire extinguishers upon employment in violation of 705.10(c)(4) Licensure Fire Safety. The paperwork was misplaced by previous administrative staff. To prevent recurrence, the Clinical Supervisor and Project Director will ensure all fire extinguisher trainings are completed and documented within one week of hire using the designated form, and all current employee files will be reviewed for compliance. Correction made 10/17/25. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training to perform assigned tasks during emergencies. Employee #6 was hired on May 19, 2025, for the position of counselor and was still employed in this position at the time of the inspection. There is no documentation in this employee's personnel record to verify this training was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility also did not have documentation verifying that the same counselor received required training to perform assigned tasks during emergencies in violation of 705.10(d)(3) Licensure Fire Safety. The paperwork was misplaced by previous administrative staff. To prevent recurrence, the Clinical Supervisor and Project Director will ensure all emergency procedure trainings are completed and documented within one week of hire using the designated form, and all current employee files will be reviewed for compliance. Correction made 10/17/25. |
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
Based on a review of the facility's annual report, the facility failed to 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.The facility's 2024 annual report did not include the names of the officers, directors or principal shareholders. Additionally, the facility did not make this report available to the public.This is a repeat citation from the July 30, 2024, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency cited under §709.22(c) was reviewed on October 21, 2025. The issue occurred because the governing body temporarily lost access to the facility's website where the annual report is typically made available to the public. The board is working to regain access, and if that cannot be restored, a new website will be developed to ensure future reports remain available for public viewing. If the development process takes longer than expected, the governing body will ensure public access by publishing the report through a local newspaper. To verify that all required information is included, the Project Director will review the annual report with the board prior to finalization. The final printed copy will include board members names before submitted, and a in house copy will be maintained as well. The Project Director will work with the board each year to ensure compliance with §709.22(c). |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policy and procedure manual, the Project Director failed to prepare, annually update and sign a written manual delineating project policies and procedures.DDAP staff reviewed the facility's policy and procedures manual, there was no documentation of the Project Director's review of the manual for 2025. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency cited under §709.23 was corrected on October 20, 2025. The Project Director reviewed the facility's policy and procedure manual in its entirety and signed and dated the 2025 annual review page to confirm compliance. The manual will continue to be reviewed and signed each year to ensure that all program policies and procedures remain current and accurately reflect DDAP standards. The Project Director is responsible for oversight of this process and for ensuring that the annual review documentation is maintained in the facility's administrative records in accordance with §709.23.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in one of two applicable personnel records reviewed. Employee #7 was hired as a counselor assistant on February 1, 2024, and was still in the position as of the date of the onsite inspection. There was no documentation of an employee annual performance evaluation in the personnel record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency cited under §709.26(b)(3) was corrected on October 20, 2025. The missing annual performance evaluation for Employee #7 was completed, reviewed, and signed by the employee. The Project Director and Clinical Supervisor will maintain a tracking log of staff hire dates and annual review due dates to ensure all evaluations are completed on time. During weekly supervision, the Clinical Supervisor will verify that evaluations are current and filed appropriately. The Project Director is responsible for oversight and ensuring continued compliance with §709.26(b)(3). |
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 the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of seven client records reviewed. Client #1 was admitted on June 23, 2025, and was still active at the time of the inspection. A release of information form for a treatment provided for September 18, 2025, did not have documentation that the client was offered a copy of the consent form. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The deficiency cited under §709.28(d) was corrected on October 6, 2025. The issue occurred because the counselor failed to have the client sign the acknowledgment section confirming that a copy of the consent form was offered. The Project Director immediately reviewed the form with the counselor, obtained the proper signature, and verified that all other active client charts are now complete. Moving forward, staff were retrained on documentation standards and confidentiality procedures to ensure all consent forms are fully completed and signed. The Clinical Supervisor will review client charts weekly during supervision to ensure all documentation remains accurate, professional, and in full compliance with DDAP requirements. The Project Director is responsible for oversight of this process. Corrective action was completed and verified on October 6, 2025 |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. Client #5 was admitted on December 26, 2024, and discharged on February 3, 2025. A review of the client's record indicated the client overdosed and was found unconscious on February 2, 2025. The facility contacted the police who arrived at the facility to aid the client. There is no documentation that the facility reported this unusual incident to DDAP. This finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
The facility reviewed the February 2, 2025, incident which was documented within the facility. The report was not communicated with DDAP because portal access was unavailable during a period of management turnover. Access has been restored, and the Project Director now maintains direct portal credentials and oversight of all incident reporting. In the event of any future incident requiring the presence of police, fire, or ambulance personnel, the Project Director will contact DDAP within three business days as required by §709.34(c)(4). Portal access will be reviewed quarterly to ensure continued compliance. The Project Director is responsible for all oversight, and corrective action was completed on October 17, 2025. |