INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development Inc. Morris 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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704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure each annual written individual training plan was based upon the employee's previous education, experience, current job functions, and performance in three of four applicable personnel records reviewed.
Employe # 2 was hired as the facility director on February 19, 2026. The individual training plan was completed on February 19, 2026; however, the training plan was not based upon the employee's previous education, experience, current job functions, and performance as the plan was identical to the training plan for the clinical supervisor and the counselor.
Employee # 3 was hired as the clinical supervisor on April 26, 2026. The individual training plan was completed on September 18, 2025; however, the training plan was not based upon the employee's previous education, experience, current job functions, and performance as the plan was identical to the training plan for the facility director and the counselor.
Employee # 4 was hired as a counselor on May 1, 2026. The individual training plan was completed on June 4, 2026; however, the training plan was not based upon the employee's previous education, experience, current job functions, and performance as the plan was identical to the training plan for the facility director and the clinical supervisor.
These findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
As a part of onboarding new staff as well as during review of annual training plan. The program director will review each plan with staff individually and identify additional trainings based on previous education, current job functions. Training plans will be reviewed quarterly as part of supervision. All training plans will be reviewed and updated by 9/15/2026 |
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 personnel records and staff schedules, the facility failed to ensure CPR certification and first aid training was 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 operations.
At the time of the inspection, the documentation reviewed showed there were no staff members, currently certified in CPR and first aid trained, working onsite at the facility during the 5:00 p.m. to 12:00 a.m. staffing shift on the following dates: April 3, 2026, April 6, 2026, April 7, 2026, April 13, 2026, April 14, 2026, April 17, 2026, April 20, 2026, April 21, 2026, April 27, 2026, April 28, 2026, May 1, 2026, May 4, 2026, May 5, 2026, May 8, 2026, May 20, 2026, May 21, May 27, 2026, and May 28, 2026.
Additionally, there were no staff members, currently certified in CPR and first aid trained, working onsite at the facility during the period of 5:00 p.m. on May 11, 2026 through 8:00 a.m. on May 12, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As part of onboarding all new employees are required to obtain CPR training/ certification. Agency/program Human Resource representative. will verify active CPR for new staff. Program Office Manager (admin support) will create an internal tracking process to document all staff CPR certification and expiration dates. Notification method will be in put in place to notify Program director and individual staff on expiration date, 30-days prior to expiration date. Program Director will review tracking tool monthly and correlating with staffing schedule to ensure 24-hour coverage by CPR certified staff. As of 7/15/2026 all current staff have active CPR certifications. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure cold food was kept at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
At the time of the inspection, which was conducted at approximately 10:15 am on June 16, 2026, the freezer, located in the kitchen, registered a temperature of 10 degrees Fahrenheit.
This is a repeat citation from the June 26, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Identified freezer was serviced following previous inspection. As a result of the current citation. A new freezer will be purchased to replace current freezer. Staff will continue to check temperature and report findings to Program Director. Anticipated date to replace current freezer by 9/15/2026. The program director will review freezer temperature logs daily. To ensure adequate oversight of refrigeration and freezer functions |
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 review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 7 was admitted on December 10, 2025 and was discharged against medical advice on January 6, 2026. There was no documentation in the record indicating the emergency contact was notified of the client's discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review AMA discharge protocol with all staff. A discharge check list will be created to support staff with a point of reference during a discharge against facility advice. The program Director will complete the checklist and meet with all staff by 9/15/2026. All new and existing clients will be made aware and reminded that identified emergency contacts will be notified in the event of.
Program Director will review all discharge checklist for clients within 48 hours for verification of completion. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in three of seven client records reviewed.
Client # 2 was admitted on December 29, 2025 and was still active at the time of the inspection. The release of information form to the emergency contact was signed by the client on December 29, 2025; however, the release form did not include documentation of the specific information to be disclosed.
Client # 3 was admitted on January 14, 2026 and was still active at the time of the inspection. The release of information form to the emergency contact was signed by the client on January 14, 2026; however, the release form did not include documentation of the specific information to be disclosed.
Client # 7 was admitted on December 10, 2025 and was discharged on January 7, 2026. The release of information form to the emergency contact was signed by the client on December 10, 2025; however, the release form did not include documentation of the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has met with all staff supporting new admissions with completion of intake packets including release of information. Program Director will review all consents within the intake packet and ongoing to ensure clients clearly identify specific information to be disclosed to emergency contacts. A staff meeting will be held to review all documents and necessary completion by 9/15/2026. Agency quality assurance department will be reviewing client charts for accuracy monthly.
Client #3 is still active and emergency ROI will corrected by 7/29/2026 |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in three of seven client records reviewed.
Client # 2 was admitted on December 29, 2025 and was still active at the time of the inspection. The release of information form to the emergency contact was signed by the client on December 29, 2025; however, the release form did not include documentation of the purpose of disclosure.
Client # 3 was admitted on January 14, 2026 and was still active at the time of the inspection. The release of information form to the emergency contact was signed by the client on January 14, 2026; however, the release form did not include documentation of the purpose of disclosure.
Client # 7 was admitted on December 10, 2025 and was discharged on January 7, 2026. The release of information form to the emergency contact was signed by the client on December 10, 2025; however, the release form did not include documentation of the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has met with all staff supporting new admissions with completion of intake packets including release of information. All existing client charts as well as clients identified in citation will sign an updated completed ROI for emergency contacts by COB Wednesday 7/22/2026. Program Director met with current program clients to discuss the purpose of disclosure related to consents. Program Director will review all consents within the intake packet and ongoing to ensure clients clearly identify specific information to be disclosed to emergency contacts. A staff meeting will be held to review all documents and necessary completion by 9/15/2026. Agency quality assurance department will be reviewing client charts for accuracy monthly. |
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 client records, the facility failed to document that a copy of a client consent was offered to the client one of seven client records reviewed.
Client # 1 was admitted on December 11, 2025 and was still active at the time of the inspection. The release of information form to a laboratory was signed by the client on December 11, 2025; however, there was no documentation in the record indicating a copy of the consent was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has met with all staff supporting new admissions with completion of intake packets to review consents. Program Director will review all consents within the intake packet and ongoing to ensure clients are clearly aware of the right to receive a copy of all signed consents. Lead Life Skills Specialist will meet with identified client from the citation to update and be offered a copy of the consent by 7/22/2026. A staff meeting will be held to review all documents and necessary completion by 9/15/2026. Agency quality assurance department will be reviewing client charts for accuracy monthly. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of two applicable client records reviewed.
Client # 4 was admitted on June 12, 2025 and was involuntarily terminated on April 30, 2026. There was no documentation, in the record, indicating the client received written notice of their involuntary termination from the project.
This is a repeat citation from the June 26, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review Administrative/involuntary discharge protocol with all staff. A discharge check list will be created to support staff with a point of reference during an involuntary discharge. The program Director will complete the checklist and meet with all staff by 9/15/2026.
Program Director will review all discharge checklist for clients and review discharge letters prior to termination. Agency Quality assurance will review staff charts monthly. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide the client with an opportunity to request reconsideration of the decision to terminate treatment in one of two applicable client records reviewed.
Client # 4 was admitted on June 12, 2025 and was involuntarily terminated on April 30, 2026. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of the involuntary termination from the project.
This is a repeat citation from the June 26, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program Director will meet with all staff to review Administrative/ involuntary discharge process. Program Director will meet with all staff and review protocol by 9/15/2026. A 24-hour notice to discharge letter will be given to clients with appeal process identified. Staff will review with clients the administrative/ involuntary discharge protocol. Program Director will review all documentation. Agency quality assurance will review charts monthly. |
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 the facility's unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident that required the presence of police and/or ambulance personnel at the facility.
There were two separate incidents, one on January 1, 2026 and the other on January 11, 2026, which required the presence of ambulance personnel on-site; however, there was no documentation indicating either incident was reported to the Department at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review unusual incident reporting protocol with all staff by 9/15/2026. Program Director will review all unusual incidents to ensure process is followed. Program Director will identify a designated folder to review reports Monthly and ensure all unusual incidents are reported within 3-days. The Program Director will submit identified missing unusual incident reports by COB Friday 7/18/2026 |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of the facility policy and procedure manual and client records, the facility failed to document, as part of their intake procedures, a physical examination, in four of five applicable client records reviewed.
The facility policy and procedure manual stated that a physical examination will be completed within one week of admission.
Client # 1 was admitted on December 11, 2025 and was still active at the time of the inspection. The physical examination was due to be completed no later than December 18, 2025; however, the examination was not completed until December 23, 2025.
Client # 2 was admitted on December 29, 2025 and was still active at the time of the inspection. The physical examination was due to be completed no later than January 5, 2026; however, the examination was not completed until January 14, 2026.
Client # 3 was admitted on January 14, 2026 and was still active at the time of the inspection. The physical examination was due to be completed no later than January 21, 2026; however, the examination was not completed until January 28, 2026.
Client # 6 was admitted on October 22, 2025 and was discharged on March 16, 2026. The physical examination was due to be completed no later than October 29, 2025; however, the examination was not completed until November 5, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has met with identified staff to review intake timeline. Program Director discussed best practices to ensure physicals are completed within 7-days of admission. Program Director will be with all staff to review process by 9/15/2026. In addition, Program Director will identify alternative providers to ensure all physicals are completed within the 7-days |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client # 1 was admitted on December 11, 2025 and was still active at the time of the inspection. The individual treatment plan was completed on December 11, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on January 14, 2026 and was still active at the time of the inspection. The individual treatment plan was completed on February 4, 2026; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has met with identified staff to review treatment plan process. The Clinical Manager will review all treatment plans with current and new clinical staff who may onboard. Staff will be educated on the importance of type and frequency being captured on the tx plan. Program Director will meet with all staff by 9/15/2026. Final review and approval of tx will be reviewed by the Program Director. Agency quality assurance department will review client charts monthly. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure counseling services were being provided according to the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client # 2 was admitted on December 29, 2025 and was still active at the time of the inspection. The individual treatment plan dated December 30, 2026 and treatment plan updates completed on January 20, 2026, February 20, 2026, March 20, 2026, April 20, 2026, and May 20, 2026 indicated the client was to receive one individual counseling session per week. There was no documentation in the record showing the client had received an individual counseling session each week during the period of February 22, 2026 through March 7, 2206 and the week of March 29, 2026.
Client #4 was admitted on June 12, 2025 and was discharged on April 30, 2026. The individual treatment plan dated June 12, 2025 and treatment plan updates completed on July 3, 2025, August 3, 2025, September 3, 2025, October 3, 2025, November 3, 2025, December 3, 2025, January 3, 2026, February 3, 2026, March 3, 2026, and April 3, 2026, indicated the client was to receive one individual counseling session per week. There was no documentation in the record showing the client had received an individual counseling session each week during the period of September 14, 2025 through October 12, 2025 and during the weeks of October 26, 2025, November 16, 2025, and March 1, 2026.
Client #5 was admitted on July 9, 2025 and was discharged on January 20, 2026. The individual treatment plan dated July 9, 2025 and treatment plan updates completed on July 29, 2025, August 29, 2025, September 29, 2025, October 29, 2025, November 29, 2025 and December 29, 2025 indicated the client was to receive one individual counseling session per week. There was no documentation in the record showing the client had received an individual counseling session during the week of September 28, 2025, as well as during each week from October 12, 2025 through December 7, 2025, and finally, during the week of January 11, 2026.
Client #6 was admitted on October 22, 2025 and was discharged on March 16, 2026. The individual treatment plan dated October 22, 2025 and treatment plan updates completed on November 12, 2025, December 12, 2025, January 12, 2026 and February 12, 2026 indicated the client was to receive one individual counseling session per week. There was no documentation in the record showing the client had received an individual counseling session during the week of October 26, 2025, as well as during each week from January 4, 2025 through March 16, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has met with the Clinical Manger and the clinician to discuss the importance of meeting for individual counseling sessions according to tx plan. Staff were reminded all clinical documentation including group and individual notes must be submitted in 24-hours.
A monthly audit tool will be created to ensure clinical documents are submitted and reviewed timely. The monthly auditing tool will be submitted to the Director of Drug and Alcohol treatment services monthly for review. The Program Director will review the audit tool prior to submission in tandem with weekly chart reviews by 9/15/2026. Agency Quality assurance department will conduct monthly chart audits. |