INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ADAPPT House 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 five personnel records, the project failed to ensure each counselor met the requirements to be a counselor by having a qualifying college degree, in one of three applicable personnel records reviewed.
Employee #3 was hired as a counselor on March 24, 2024 and was a current employee at the time of the inspection. The employee possessed an Associate ' s Degree that did not meet the requirements approved by the Department as being a qualifying degree for the position of counselor.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Employee #3 was hired as a counselor on March 24, 2024 and was a current employee at the time of the inspection. The employee possessed an Associate ' s Degree that did not meet the requirements approved by the Department as being a qualifying degree for the position of counselor.
As of 1/29/26, employee #3 is no longer a Substance Abuse Counselor at ADAPPT. The Facility Director and AFD of programs will work with the human resources department at our Corporate Office to implement a comprehensive verification protocol during interview process; in which candidate will provide physical degrees/ certifications/ transcripts as well as official channels before extending job offer. Additionally, we are actively updating our job descriptions along side of our Corporate Office to clearly outline the required qualifications.
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705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection, conducted on January 7, 2026, the facility failed to ensure that all bunk beds were equipped with a securely attached railing on each open side of the bunk.
The bunk beds in all client rooms were not equipped with a securely attached railing on each open side of the bed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The bunk beds in all client rooms were not equipped with a securely attached railing on each open side of the bed.
On February 13, 2026, the facility director (FD) conducted a full facility walkthrough of the housing areas to determine how many bunks required railings and ladders as required under standard 707.5 (b). On February 17, 2026, the FD obtained quotes for railing and ladder attachments to be affixed to the existing bunks. By February 18, 2026, the (FD) will submit the quote and expenses to GEO's Corporate Finance Department to obtain the appropriate review and approvals before placing the order. In the interim, all clients who currently are on a top bunk will now move to a lower bunk. All beds will be disassembled to a lower bunk by February 27, 2026. The (FD) or designee will ensure no new placements are assigned to a top bunk until the railing and ladder attachments have been ordered, received, and securely fastened to the existing bunks. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed.
Client #3 was admitted on November 26, 2025 and was active at the time of the inspection. On December 16, 2025, a family member participated in the client ' s therapy session; however, there was not a release of information signed by the client, prior to the disclosure.
Client #4 was admitted on October 17, 2025 and was discharged on December 17, 2025. On November 13, 2025, November 18, 2025, November 25, 2025, December 3, 2025 and December 9, 2025, a family member participated in the client ' s therapy session; however, there was not a release of information signed by the client, prior to the disclosure.
This is a repeat citation from the December 17, 2024, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.28. Confidentiality. (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: (1) Name of the person, agency, or organization to whom disclosure is made.
On 1/08/2026, the Clinical Director had a staff meeting to provide refresher training which included the requirement of obtaining informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made. Clinical Director will ensure that all consent forms are maintained in clinical files by completing her weekly and monthly audit of client charts. On 1/8/26, Client did sign a release of information for their family member. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in one of seven records reviewed.
Client #7 was admitted on September 24, 2025 and was discharged on November 24, 2025. A release of information form signed by the client on September 25, 2025, did not specify the name of the person, agency or organization to whom disclosure is to be made.
This is a repeat citation from the December 17, 2024, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.28. Confidentiality. (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: (1) Name of the person, agency, or organization to whom disclosure is made.
On 1/08/2026, the Clinical Director had a staff meeting to provide refresher training which included the requirement of obtaining informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made. Clinical Director will ensure that all consent forms are maintained in clinical files by completing her weekly and monthly audit of client charts. |
709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the date event, or condition upon which the consent will expire in three of seven records reviewed.
Client #2 was admitted on November 26, 2025 and was active at the time of the inspection. A release of information for the local hospitals, a funding source and a social services agency signed by the client on November 27, 2025, did not document the date, event, or condition upon which the consent will expire.
Client #3 was admitted on November 26, 2025 and was active at the time of the inspection. A release of information for the local hospitals, a funding source and a social services agency signed by the client on November 29, 2025, did not document the date, event, or condition upon which the consent will expire.
Client #4 was admitted on October 17, 2025 and was discharged on December 17, 2025. A release of information for the local hospitals, a funding source and a social services agency signed by the client on October 18, 2025, did not document the date, event, or condition upon which the consent will expire.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.28 (c) (6) Confidentiality § 709.28. Confidentiality. (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: (6) Date, event or condition upon which the consent will expire.
On 1/08/2026, the Clinical Director had a staff meeting to provide refresher training for clinical staff which included the requirement of obtaining informed and voluntary consent from the client for the disclosure of information contained in the client record. Clinical Director will ensure that all consent forms are maintained in clinical files by completing her weekly and monthly audit of client charts. Clinical Director will also ensure that the expiration date is one year from the time of signing and that clients have a right at any time to revoke any releases they may have. On 1/8/26, the information was corrected for clients #2 and #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 the review of client records, the project failed to offer a copy of the release of information forms in one of seven client records reviewed.
Client #7 was admitted on September 24, 2025 and was discharged on November 24, 2025. There was no documentation that the client was offered a copy of the release of information form for the department of corrections; signed and dated by the client on September 25, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.28. Confidentiality. (d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
On 1/08/2026, the Clinical Director had a staff meeting to provide refresher training which included the requirement of offering all clients a copy of their consent forms that they signed on intake. Clinical Director will ensure that all consent forms are maintained in clinical files by completing her weekly and monthly audit of client charts. |
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 the review of client records, the project failed to document a complete client record on an individual that included follow-up contact within seven days post discharge, per facility policy, in one of three applicable records reviewed.
Client #4 was admitted on October 17, 2025 and was discharged on December 17, 2025. There was no follow-up contact information documented in the client record seven days post discharge.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 1/8/26, all client files will include a follow up for clients after being discharged within 7 days. Facility Director will monitor this by checking files. The project manager will monitor the process for 90 days or until compliance is achieved. Counselor attempted to make contact on 1/8/26 but was not able to reach him |