INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2026, 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director met both the education and experiential qualifications for the position. Employee #2 was hired on October 15, 2023, and was promoted to facility director October 15, 2025, and is still current in that position. Employee #2 does not have a qualifying degree or documented experiential qualifications for the position.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A project shall have a Facility Director who meets the required qualifications under the regulation.
The facility reviewed the citation under 28 Pa. Code § 704.5(c), regarding Facility Director qualifications.
Upon review, the facility identified that Employee #2 was listed under Facility Director qualifications on the staffing form. Employee #2 was not promoted to Facility Director. Employee #2 was promoted to Assistant Project Director / Assistant to the Project Director on October 15, 2025.
To correct the deficiency, Employee #2 will not be listed, hired, or submitted as Facility Director unless the employee meets the qualifications under 28 Pa. Code § 704.5(c), or unless approval is received through the appropriate Department process.
The facility corrected staffing documentation to reflect Employee #2's actual role as Assistant Project Director / Assistant to the Project Director.
Moving forward, before any employee is hired, promoted, or submitted as Facility Director, the facility will complete a qualification review. This review will include the employee's education, experience, and supporting documentation to confirm the employee meets the Facility Director qualification requirements.
The Project Director will review staffing forms and qualification documentation before submission. The governing body / Owner-Operator will review and approve any Facility Director hiring, promotion, or submission before the employee is listed as Facility Director.
To prevent recurrence, the Project Director will monitor staffing documentation before submission to ensure employee titles, job categories, education, experience, and assigned roles are accurate. The governing body / Owner-Operator will provide final review for Facility Director hiring, promotion, or submission decisions.
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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 a counselor met the educational qualifications for the position in one out of six records reviewed. Employee #6 was hired as a Counselor on December 29, 2025, and was still in that position at the time of inspection. Employee #6 had an associate ' s degree in general studies, which is not a qualifying major for the position.This is a repeat citation from the October 3, 2025, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility reviewed the citation and the personnel record for Employee #6. Based on this review, the facility understands that the Associate's Degree in General Studies documented in the personnel file does not meet the qualifying degree major requirement for the Counselor position under 28 Pa. Code § 704.7(b).
Employee #6 was originally listed as a Counselor based on documented work history and prior counseling-related experience. After review of the citation and qualification requirement, the facility understands that the degree major on file does not meet the regulatory requirement for the Counselor position.
Effective July 10, 2026, Employee #6 will be listed as AS, CA moving forward and will not be counted as a Counselor for staffing or counselor-to-client ratio purposes.
Employee #6 will remain listed as AS, CA unless and until qualifying measures are completed and documented that allow the employee to be submitted under a different approved position classification. This may include completion of qualifying education, and/or full addiction counselor certification such as CADC if applicable, or another approved qualification pathway accepted under the regulation.
The Project Director, with appropriate clinical leadership review, will ensure that the staffing report, personnel file, and internal documentation accurately reflect Employee #6's approved position classification.
To prevent recurrence, the Project Director or designee will complete a thorough credential verification and qualification review before any employee is hired, promoted, or submitted as a Counselor. This review will include the employee's application, resume, degree, major, transcripts when applicable, diploma or degree documentation, certifications, licensure, documented clinical experience, work history, reference checks when applicable, and comparison to the applicable regulatory qualification requirement.
Qualification review documentation will be maintained in the personnel file. The Project Director will review and approve the qualification documentation before the employee is submitted under a Counselor position classification.
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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 the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level, to be completed annually at the start of the new year, per facility policy, in one out of nine personnel records reviewed.Employee #1 was hired on August 5, 2019, was promoted to project director on December 1, 2024, and was still in the position as of the date of the inspection. There was no documentation of an individual training plan dated for 2026. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility reviewed the citation under 28 Pa. Code § 704.11(b)(1), Individual Training Plan, and the personnel documentation for Employee #1. Upon review, the facility confirmed that individual training plan documentation was completed for Employee #1.
The facility has documentation of an individual training plan dated 01/09/2024, when Employee #1 was listed under the job title of Primary Counselor. The facility also has documentation of an individual training plan dated 01/16/2025, which specifically listed Employee #1 under the title of Project Director. In addition, the facility has a 01/22/2026 individual training plan for Employee #1 under the title of Project Director, which addressed annual DDAP training requirements.
Employee #1 also has a personnel evaluation dated 08/03/2025, which was completed as part of the facility's corrective efforts following the prior inspection.
The facility understands that the issue appears to have occurred during document submission and organization. When Employee #1's personnel evaluation was requested, the 2026 individual training plan was not submitted with the personnel evaluation documentation.
The 01/22/2026 individual training plan will be placed with Employee #1's personnel file documentation and submitted as supporting documentation.
To prevent recurrence, the Project Director will be responsible for reviewing employee file documentation before submission to ensure requested documents are complete, organized, and properly maintained. This review will include personnel evaluations, individual training plans, annual training records, and related staff development documentation.
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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 (SRFSR) form, the facility failed to ensure that employees received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in eleven out of twenty-six records reviewed. Employee #2 was hired as a house manager on October 15, 2023, promoted to a counselor assistant on February 1, 2024, and was then promoted to facility director on October 15, 2025. Employee #2 was due to have the communicable disease trainings no later than February 1, 2025. There was no documentation in the personnel record of the TB/STD training as of the date of the inspection. Employee #10 was hired as a manager on August 22, 2014, and was due to have the communicable disease trainings no later than August 22, 2016. There was no documentation in the personnel record of the TB/STD training as of the date of the inspection.Employee #11 was hired as a manager on May 28, 2023, and was due to have the communicable disease trainings no later than May 28, 2025. There was no documentation in the personnel record of the completion of the TB/STD training as of the date of the inspection.Employee #12 was hired as a house manager on January 2, 2023, and was due to have the communicable disease trainings no later than January 2, 2025. There was no documentation in the personnel record of the completion of the TB/STD training as of the date of the inspection.Employee #13 was hired as an administrative assistant on March 19, 2019, and was due to have the communicable disease trainings no later than March 19, 2021. There was no documentation in the personnel record of the completion of the TB/STD training or the HIV/AIDS training as of the date of the inspection. Employee #14 was hired as a medication manager on October 25. 2013, and was due to have the communicable disease trainings no later than October 25, 2015. There was no documentation in the personnel record of the completion of the TB/STD training as of the date of the inspection.Employee #15 was hired as a house manager on February 1, 2024, and was due to have the communicable disease trainings no later than February 1, 2026. There was no documentation in the personnel record of the completion of the TB/STD training as of the date of the inspection.Employee #16 was hired as a house manager on February 10, 2023, and was due to have the communicable disease trainings no later than February 10, 2025. There was no documentation in the personnel record of the completion of the TB/STD training as of the date of the inspection.Employee #17 was hired as a house manager on February 10, 2023, and was due to have the communicable disease trainings no later than February 10, 2025. There was no documentation in the personnel record of the completion of the TB/STD training as of the date of the inspection.Employee #18 was hired as the owner and support staff on January 2, 2008, and was due to have the communicable disease trainings no later than January 2, 2010. There was no documentation in the personnel record of the completion of the TB/STD training or of the HIV/AIDS training as of the date of the inspection. Employee #26 was hired as a house manager on November 29, 2023, and was due to have the communicable disease trainings no later than November 29, 2025. There was no documentation in the personnel record of the completion of the TB/STD training as of the date of the inspection. This is a repeat citation from the October 3, 2025, licensing inspection. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
704.11(c)(1)
Staff shall complete required communicable disease training.
The facility reviewed the citation under 28 Pa. Code § 704.11(c)(1), regarding required communicable disease training.
Upon review, the facility identified that TB/STD and/or HIV/AIDS training documentation was missing from the cited employee records.
To correct the deficiency, the facility reviewed the cited personnel files, retrieved completed training documentation where available, and scheduled the outstanding required training for employees who had not completed the required training.
The facility identified the following completed or scheduled training dates:
Employee #14: TB/STD training documentation retrieved. Training completed on 06/29/2017.
Employee #2: TB/STD training scheduled for 12/03/2026.
Employee #10: TB/STD training completed on 06/29/2017.
Employee #11: TB/STD training scheduled for 09/25/2026.
Employee #12: TB/STD training scheduled for 12/03/2026.
Employee #13: TB/STD training completed on 11/12/2019.
Employee #15: TB/STD training scheduled for 10/20/2026.
Employee #16: TB/STD training scheduled for 12/03/2026.
Employee #17: TB/STD training scheduled for 08/24/2026.
Employee #18: HIV/AIDS training scheduled for 08/06/2026. TB/STD training scheduled for 08/24/2026.
Employee #26: TB/STD training scheduled for 12/03/2026.
Training certificates will be placed in each employee's personnel file upon completion.
To prevent recurrence, the Assistant to the Project Director will assist with organizing and tracking required employee training documentation. The Project Director will review employee training records monthly to verify that required communicable disease trainings are completed within the required timeframe and maintained in the personnel file.
If required communicable disease training is missing during monthly review, the Project Director will ensure the training is scheduled, completed, and placed in the employee's personnel file.
If a scheduled training is delayed due to waitlist status or course availability, the Project Director will document the delay and ensure the employee is rescheduled for the next available training date.
The corrective action was completed on 07/30/2026 by reviewing the cited personnel files, retrieving available completed training documentation, and scheduling the outstanding required trainings.
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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 administrative documents, the facility failed to provide a schedule identifying employees and the hours worked to demonstrate that CPR certification and first aid training were provided to a sufficient number of project staff so that at least one person trained in these skills is onsite during the project's hours of operation.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility reviewed the citation under 28 Pa. Code § 704.11(c)(2), CPR Certification and First Aid Coverage, and reviewed the facility's time cards, sign-in/sign-out logs, employee schedules, and CPR/First Aid certification records.
At the time of inspection, the facility maintained time cards, sign-in/sign-out logs, and employee schedules to document staff presence and hours worked. However, the facility was not maintaining a weekly CPR/First Aid coverage verification log to clearly show that at least one CPR/First Aid certified staff person was onsite during all hours of operation.
To correct the deficiency, the facility created a Weekly CPR/First Aid Coverage Verification Log on 07/10/2026. The log was completed for the review period beginning 06/01/2026 by cross-referencing time cards, sign-in/sign-out logs, employee schedules, and CPR/First Aid certification records to verify coverage.
The Weekly CPR/First Aid Coverage Verification Log identifies the day, shift, staff on shift, CPR/First Aid certified staff on shift, coverage confirmation, and a notes section for staffing changes, schedule adjustments, or other coverage-related information.
The weekly log includes the facility's operating shifts of 7:00 AM to 3:30 PM, 2:30 PM to 11:00 PM, and 10:30 PM to 7:00 AM.
The requested CPR/First Aid coverage information for the Department-requested review period will be provided no later than 08/07/2026.
The Assistant to the Project Director will assist with preparing and maintaining the weekly CPR/First Aid coverage verification log. The Project Director will review the log to confirm that coverage is documented and that at least one CPR/First Aid certified staff person is onsite during each shift.
To prevent recurrence, the facility will maintain the Weekly CPR/First Aid Coverage Verification Log on an ongoing basis. The Project Director will be responsible for reviewing the log to ensure CPR/First Aid coverage is documented and properly maintained. Documentation may be cross-referenced with time cards, sign-in/sign-out logs, employee schedules, and CPR/First Aid certification records as needed.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director completed at least 12 clock hours of training annually in one out one applicable record reviewed. Employee #1 was hired as the project director on December 1, 2024, and was current in that position at the time of the inspection. There were only 9 clock hours of training documented in the personnel record. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility reviewed the citation under 28 Pa. Code § 704.11(d)(2), regarding annual training requirements for the Project Director.
Upon review, the facility identified that Employee #1 had 9 documented clock hours of annual training in the personnel record at the time of inspection. The facility understands that Employee #1 was missing 3 clock hours of annual training.
To correct the deficiency, Employee #1 is scheduled to complete a 3-hour ethics training on 08/14/2026. This training will complete the remaining 3 clock hours needed for Employee #1's annual training documentation.
Employee #1 is responsible for completing the 3-hour ethics training on 08/14/2026.
The Assistant to the Project Director will monitor the correction by tracking the scheduled training date, confirming completion on 08/14/2026, and verifying that the training certificate or supporting documentation is placed in Employee #1's personnel file.
To prevent recurrence, annual training hours will be tracked throughout each training year. The Project Director, Assistant to the Project Director, and Lead Counselor will review annual training hours quarterly to verify completed hours are documented and to ensure required annual training hours are being completed.
Annual training hours will be tracked using the employee training record and individual training plan. The Project Director is responsible for ensuring required annual training hours are completed. The Assistant to the Project Director will assist with organizing and tracking training documentation. The Lead Counselor will assist with quarterly review of training records related to clinical staff training compliance.
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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 9, 2026, the facility failed to provide either individual paper towels or a mechanical dryer in the bathroom located on the first floor of the building near the TV and medication room. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the residential facility shall provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
The facility reviewed the citation under 28 Pa. Code § 705.6(2), Bathrooms, regarding the first-floor bathroom located near the TV and medication room.
To correct the deficiency, individual paper towels were placed in the first-floor bathroom near the TV and medication room. The bathroom will continue to be supplied with individual paper towels or another approved drying method as required.
To prevent recurrence, the Lead Manager will be responsible for checking bathroom supplies and addressing missing items during routine facility checks. These checks will include verification that bathrooms have required supplies, including paper towels or an approved drying method.
The Project Director will provide oversight to ensure bathroom supply checks are being completed and that required bathroom supplies are maintained.
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705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection on July 9, 2026, the facility failed to provide toilet paper in the bathroom located on the first floor of the building near the TV and medication room. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.6(6) Bathrooms
The residential facility shall provide toilet paper at each toilet at all times.
The facility reviewed the citation under 28 Pa. Code § 705.6(6), Bathrooms, regarding the first-floor bathroom located near the TV and medication room.
To correct the deficiency, toilet paper was placed in the first-floor bathroom near the TV and medication room. The bathroom will continue to be supplied with toilet paper at each toilet as required.
To prevent recurrence, the Lead Manager will be responsible for checking bathroom supplies and addressing missing items during routine facility checks. These checks will include verification that toilet paper is available at each toilet.
The Project Director will provide oversight to ensure bathroom supply checks are being completed and that required bathroom supplies are maintained.
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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 on July 9, 2026, the facility failed to limit smoking to designated smoking areas. Used cigarette butts were observed within the 3rd and 2nd floor fire escape stairwells and in a coffee mug on the 2nd floor fire escape on the rear of the building. Facility staff confirmed that the designated smoking area is on the ground floor behind the building below the fire escapes. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.9(3) General safety and emergency procedures
The residential facility shall limit smoking to designated smoking areas.
The facility reviewed the citation under 28 Pa. Code § 705.9(3), General Safety and Emergency Procedures, regarding cigarette butts observed in non-designated smoking areas, including the fire escape stairwells and rear fire escape area.
To correct the deficiency, cigarette butts were removed from the non-designated smoking areas. Staff and residents were reminded that smoking is only permitted in the designated smoking area located behind the building on the ground floor.
To further correct the deficiency and reinforce facility expectations, the 9:00 AM Morning Meditation groups on 07/22/2026, 07/23/2026, and 07/24/2026 will include review of the importance of smoking only in designated areas and keeping fire escapes, stairwells, and other non-designated areas free from smoking activity.
To prevent recurrence, the Lead Manager will be responsible for the monitoring of non-designated smoking areas during routine facility checks, including fire escapes, stairwells, and other areas where smoking is not permitted. The Lead Manager will address smoking-related concerns as they are identified and will reinforce that smoking is only permitted in the designated smoking area.
The Project Director will provide oversight to ensure monitoring is being completed and that smoking remains limited to the designated smoking area.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection on July 9, 2026, the facility failed to ensure that stairways, hallways, and exits from rooms and form the residential facility are unobstructed. The exit door to the green stairwell in the efficiency wing on the second floor of the building was partially obstructed by paint cans. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.10(a)(1)(i) Fire safety
Exits, stairways, and fire escapes shall be unobstructed.
The facility reviewed the citation under 28 Pa. Code § 705.10(a)(1)(i), Fire Safety, regarding roof coating supplies partially obstructing the green stairwell exit in the efficiency wing on the second floor.
The facility had roof-related work completed in May 2026, and the items observed were supplies connected to that project. To correct the deficiency, the roof coating supplies were removed from the green stairwell exit area and taken to the basement for appropriate storage. The exit area will remain clear and unobstructed.
To prevent recurrence, project-related supplies, maintenance materials, and storage items will not be placed in exits, stairwells, fire escapes, or other required means of egress. The Lead Manager will be responsible for the monitoring of exit areas during routine facility checks to ensure stairwells, fire exits, and walkways remain clear and unobstructed.
The Project Director will provide oversight to ensure exit areas are monitored and maintained in accordance with fire safety requirements.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of administrative documents, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There were no fire drills conducted during sleeping hours during the months of October 2025 through June 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.10(d)(5) Fire drills
A fire drill shall be held during sleeping hours at least once every 6 months.
The facility reviewed the citation under 28 Pa. Code § 705.10(d)(5), Fire Drills, regarding the requirement that a fire drill be held during sleeping hours at least once every 6 months.
Upon review, the facility determined that the issue involved fire drill documentation. The facility identified a fire drill entry from April 2026 where the penmanship did not clearly confirm whether the drill was completed during AM or PM hours.
To correct the deficiency, the facility reviewed the fire drill documentation process and updated expectations to ensure that each fire drill log clearly identifies the date, time, AM or PM designation, evacuation route used, staff involved, client participation, evacuation time, and any issues identified during the drill.
The facility will continue to conduct sleeping-hour fire drills at least once every 6 months and will ensure that each sleeping-hour fire drill is clearly documented.
To prevent recurrence, the Assistant to the Project Director will assist with reviewing and organizing fire drill documentation for completeness and clarity. The Project Director will review the documentation with the Assistant to the Project Director and will remain responsible for final oversight, correction, and compliance with fire drill requirements.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of administrative documents, the facility failed to prepare alternate exit routes in nine out of nine fire drill logs reviewed. All fire drills recorded on the log indicated that the front exit was used. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.10(d)(6) Fire drills
Fire drill procedures shall include the use and documentation of alternate exit routes.
The facility reviewed the citation under 28 Pa. Code § 705.10(d)(6), Fire Drills, regarding fire drill documentation showing the same front exit route used on the fire drill logs reviewed.
Upon review, the facility determined that the issue involved fire drill procedure and documentation. The facility understands that fire drill records must clearly identify the exit route used and that alternate evacuation routes must be included so staff and clients are familiar with more than one evacuation route.
To correct the deficiency, beginning 07/10/2026, the facility will improve the fire drill documentation process moving forward to ensure that each fire drill log clearly identifies the exit route used. Alternate exit routes will be documented moving forward, including the front and back doors of the 199 building, the front door near the counselor office, and the back door of the 207 building.
To prevent recurrence, the Assistant to the Project Director will assist with reviewing and organizing fire drill documentation for completeness and accuracy. The Project Director will review the documentation with the Assistant to the Project Director and will remain responsible for final oversight, correction, and compliance with fire drill requirements.
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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 administrative documents, the project failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders.The 2025 annual report, which was published in the local newspaper on December 31, 2025, did not disclose the names of officers, directors and principal shareholders.This is a repeat citation from the July 30, 2024, and the October 3, 2025, licensing inspections. This finding was reviewed with project staff during the licensing process.
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Plan of Correction
709.22(c)
If a facility is publicly funded, the governing body shall make available to the public an annual report which includes required information, including the names of officers, directors, and principal shareholders, when applicable.
The facility reviewed the citation under 28 Pa. Code § 709.22(c), regarding the annual report not clearly identifying the required governing body information.
Upon review, the facility determined that the project's governing body is the Owner/Operator, who has legal responsibility for the project.
To correct the deficiency, the 2026 Annual Report will be reviewed, revised to clearly identify the governing body as the Owner/Operator, published, and made available as required no later than 09/30/2026.
To prevent recurrence, the Assistant to the Project Director will assist with organizing and reviewing annual report documentation for completeness before final review. The Project Director will review the annual report with the Assistant to the Project Director and will remain responsible for final oversight, correction, approval, and compliance with annual report requirements.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the facility ' s policy manual, the facility failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice in two out of two applicable records reviewed.Client #3 was admitted on May 14, 2026, and left against medical advice on June 5, 2026. There was no documentation in the record that the emergency contact was notified. Client #4 was admitted on February 10, 2026, and left against medical advice on February 23, 2026. There was no documentation in the record that the emergency contact was notified. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.24(a)(3)
The governing body shall adopt written procedures for the management of treatment services for clients.
The facility reviewed the citation under 28 Pa. Code § 709.24(a)(3), regarding the facility not following its written procedure for emergency contact notification within 12 hours after an AFA discharge.
Upon review, the facility identified that the cited records did not clearly document emergency contact notification within 12 hours after AFA discharge, or documentation showing that the client had revoked consent for emergency contact notification.
To correct the deficiency, the facility revised intake documentation to include an Emergency Contact Notification Consent After AFA Discharge section. This section uses the language from Licensing Alert 02-21 and informs the client that if the client leaves the facility AFA, the facility will notify the emergency contact, provided the client has not revoked consent to notify if one is on file.
The revised documentation allows the client to maintain or revoke consent for emergency contact notification after an AFA discharge. The client's selection will be documented in the client record.
Beginning 07/31/2026, if a client leaves the facility AFA and consent has been maintained, staff will complete and document an emergency contact notification attempt within 12 hours. Documentation will include the date, time, method of contact, result of the attempt, and staff completing the documentation.
If the client revokes consent for emergency contact notification after an AFA discharge, staff will document the revoked consent in the client record as the reason emergency contact notification was not completed.
To prevent recurrence, counselors will be responsible for completing and documenting emergency contact notification information after an AFA discharge in accordance with the facility's written procedure and the client's documented consent status. The Lead Counselor will review discharge documentation for accuracy and required emergency contact notification documentation. The Project Director will provide oversight to ensure the facility follows its written procedures and regulatory requirements.
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709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of client records, the facility failed to record medication errors in the client record in two out of two applicable records reviewed.Client #6 was admitted on June 5, 2026, and was active at the time of inspection. The client was prescribed Omeprazole 20 mg caplet self-administered once daily. There was no documentation that the client received or refused the medication on July 1, 2026, July 2, 2026, July 3, 2026, July 4, 2026, July 5, 2026, July 6, 2026, July 7, 2026, July 8, 2026, or July 9, 2026.Client #7 was admitted on May 18, 2026, and was active at the time of inspection. The client was prescribed:Losartan HCTZ 50 12.5mg, daily in the morning. There was no documentation that the client received or refused the medication on July 3, 2026, July 7, 2026, or July 8, 2026. Tamsulosin 0.4mg, daily in the evening. There was no documentation that the client received or refused the medication on July 2, 2026, July 7, 2026, or July 8, 2026. Docusate 100mg, twice daily. There was no documentation that the client received or refused the medication for their morning or evening dose on July 1, 2026, their evening dose on July 2, 2026, their morning dose on July 3, 2026, their morning or evening dose on July 7, 2026, their morning or evening dose on July 8, 2026, or their morning dose on July 9, 2026. Buprenorphine/Nalox. film 8-2mg two films per day. There was no documentation that the client received or refused the medication for their morning dose on June 14, 2026, June 19, 2026, June 20, 2026, June 21, 2026, June 25, 2026, or June 28, 2026, their evening dose on July 1, 2026, their morning dose on July 3, 2026, their morning dose on July 7, 2026, or their morning dose on July 8, 2026.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility reviewed the citation under 28 Pa. Code § 709.32(c)(6), regarding medication errors and drug reactions being recorded in the client record.
Upon review, the facility identified that the medication documentation for the cited records did not clearly show what occurred on the identified dates.
To correct the deficiency, beginning 07/24/2026, medication room staff will document when a client is out of medication or when a client does not want to take medication.
When a client does not want to take medication, medication room staff will document "did not take, counselor notified" on the medication sheet. The counselor will attempt to meet with the client within 24 hours, complete a case management note in the client record, and have the client sign medication refusal documentation with the counselor. If the counselor is unable to meet with the client within 24 hours, the reason will be documented in the client record.
When a client is out of medication, medication room staff will notify the client and document "out of medication, client notified" on the medication sheet. The client is responsible for contacting the prescribing provider or pharmacy regarding the refill.
To prevent recurrence, medication room staff will document when a client is out of medication or does not want to take medication. Counselors will complete related case management documentation. When a client does not want to take medication, counselors will also complete medication refusal documentation with the client. The Lead Counselor will review medication-related documentation for accuracy and required medication documentation. The Project Director will provide oversight to ensure medication documentation is completed and maintained in the client record.
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709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support service on individual treatment plans in five out of seven records reviewed.Client #1 was admitted on November 26, 2025, and was discharged on March 15, 2026. The comprehensive treatment plan dated November 26, 2025, did not include the proposed type of support service.Client #2 was admitted on October 30, 2025, and was discharged on January 10, 2026. The comprehensive treatment plan dated October 30, 2025, did not include the proposed type of support service.Client #3 was admitted on May 14, 2026, and was discharged on June 5, 2026. The comprehensive treatment plan dated May 14, 2026, did not include the proposed type of support service.Client #4 was admitted on February 10, 2026, and was discharged on February 23, 2026. The comprehensive treatment plan dated February 10, 2026, did not include the proposed type of support service.Client #7 was admitted on May 18, 2026, and was active at the time of inspection. The comprehensive treatment plan dated May 18, 2026, did not include the proposed type of support service.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.52(a)(3)
The treatment plan shall include the proposed type of support service.
The facility reviewed the citation under 28 Pa. Code § 709.52(a)(3), regarding treatment plans missing the proposed type of support service in the client record.
To correct the deficiency, the Project Director and Lead Counselor addressed the importance of documenting support services in the treatment plan during a staff meeting on 07/15/2026.
Beginning 07/24/2026, all treatment plans documented after this date will include support services in the "Interventions Utilized" section, appropriate to each treatment goal. This will ensure the treatment plan clearly identifies the support services being used or proposed as part of the client's treatment.
To prevent recurrence, counselors will be responsible for documenting support services in the "Interventions Utilized" section, appropriate to each treatment goal. The Lead Counselor will review treatment plan documentation for clinical completeness and accuracy at intake completion, 30-day treatment plan review, 60-day treatment plan review, and 90-day treatment plan review. This review will include verifying that support services are documented in the "Interventions Utilized" section, appropriate to each treatment goal.
The Project Director will provide oversight to ensure treatment plan documentation meets facility and regulatory requirements.
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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 which includes information relative to the client ' s involvement with the project, including follow-up information, in one out of two applicable records. Client #4 was admitted on February 10, 2026, and left against facility advice on February 23, 2026. The record contained no documentation that a follow up occurred. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.53(a)(11)
The client record shall include follow-up information.
The facility reviewed the citation under 28 Pa. Code § 709.53(a)(11), regarding follow-up information missing from the client record for Client #4 following an AFA discharge.
Upon review, the facility identified that the client record did not clearly document follow-up information or follow-up contact status after discharge.
To correct the deficiency, the facility revised the Client Contract to include a Follow-Up Contact Preference section for administrative discharge, involuntary discharge, or AFA discharge. This section allows the client to document at intake whether the client consents to or declines follow-up contact if the client is administratively discharged, involuntarily discharged, or leaves the facility AFA.
Beginning 07/31/2026, follow-up contact preference documentation will be completed at intake and maintained in the client record. If a client later leaves AFA or is administratively or involuntarily discharged before discharge paperwork can be completed, the client record will still identify the client's follow-up contact preference.
All discharge documentation will accurately identify the follow-up contact status, including whether follow-up contact was consented to, declined, completed, or attempted.
To prevent recurrence, counselors will be responsible for completing discharge documentation accurately and ensuring the follow-up contact status is clearly documented in the client record. The Lead Counselor will review discharge documentation for accuracy and required follow-up documentation. The Project Director will provide oversight to ensure discharge documentation meets facility and regulatory requirements.
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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 the annual report was submitted by the Department for the July 30, 2024, and October 3, 2025, annual licensing inspections. Failing to identify the members of the governing body in the annual report as again found to be a deficiency in the July 9, 2026, licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility reviewed the citation under 28 Pa. Code § 709.17(a)(3), regarding failure to comply with a plan of correction approved by the Department.
Upon review, the facility identified the need for a stronger follow-through process to ensure approved Plans of Correction are reviewed, monitored, and completed within the stated timeframe.
To correct the deficiency, beginning 08/01/2026, the governing body will implement a monthly Plan of Correction follow-through review process. This process will consist of monthly checks between the governing body and the Project Director regarding the status and follow-through of approved Plans of Correction.
The Project Director will be responsible for carrying out approved corrective actions, confirming completion of required corrections, and ensuring documentation is available to support compliance.
To prevent recurrence, the governing body will conduct monthly checks with the Project Director to review active Plans of Correction, confirm completion dates, identify any outstanding corrective actions, and ensure required documentation is available for review. The Assistant to the Project Director may assist with organizing supporting documentation for the Project Director's review.
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