INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 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 Resurrection 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to have a counselor complete the required minimum of at least 25 clock hours of training annually in one of one applicable record reviewed.
Employee #3 was hired on October 28, 2024 and was current in that position. The personnel record documented only six hours of annual training for the 2025 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor met with employee #3 on 4/08/2026 and discussed the training hour requirement for regulation 704.11 (f)2. Employee #3 is currently pursuing training hours to achieve compliance. Clinical Supervisor will meet with employee #3 monthly to track training hours to ensure compliance with required hours. Clinical Supervisor will document training progress in monthly supervision reports. In addition to employee #3, Clinical Supervisor will monitor all staff training hours to ensure compliance. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on review of administrative documents the facility failed to have the project director prepare, annually update and sign a written manual delineating project policies and procedures.
The project director did not provide an annually signed manual at time of licensing inspection on April 7, 2026.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 4/08/2026, HR Director met with Project Director to ensure written policy and procedure manual was reviewed. Project Director executed a policy review. HR Director will ensure Project Director reviews and executes the signing of the manual annually, prior to licensing inspections. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on review of administrative documents, facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The facility was unable to provide documentation of an annual financial audit for the year 2024 during the licensing process.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Owner, Chris Cawley, informed DDAP inspectors on day of inspection 4/7/2026 that due to separation of ownership, new owner was unable to obtain 2024 audit; therefore, owner and Project Director will ensure that financial audit is completed annually by CPA for the project's accounting principles. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained an annual written performance evaluation that was reviewed and signed by the employee in two of two applicable personnel records reviewed.
Employee #2 was hired as the clinical supervisor on October 1, 2024 and was current in that position at the time of the licensing inspection. There was no documentation that an annual performance evaluation was completed for 2025.
Employee #3 was hired as a counselor on October 28, 2024 and was current in that position at the time of the licensing inspection. There was no documentation that an annual performance evaluation was completed for 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HR Director informed DDAP inspectors on date of inspection (4/7/2026) that due to the separation in ownership at the end of 2025, some data from personnel files were not made available from previous owner during ownership transition, which include performance reviews. HR Director will ensure all personnel performance reviews are completed and documented according to company policies annually. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in five out of seven records reviewed.
Client # 3 was admitted to the residential level of care on August 14, 2025 and was discharged on November 14, 2025. The informed and voluntary consent form for the funding source was not signed until August 27, 2025, however; the facility confirmed billing started on August 14, 2025.
Client # 4 was admitted to the residential level of care on January 19, 2026 and was discharged on March 21, 2026. There was no informed and voluntary consent form for the funding source in client record. The facility confirmed billing occurred.
Client # 5 was admitted to the residential level of care on January 23, 2026 and was active at the time of licensing process. There was no informed and voluntary consent form for the funding source in client record. The facility confirmed billing occurred.
Client # 6 was admitted to the residential level of care on February 18, 2026 and was active at the time of licensing process. There was no informed and voluntary consent form for the funding source in client record. The facility confirmed billing occurred.
Client # 7 was admitted to the residential level of care on January 29, 2026 and was active at the time of licensing process. There was no informed and voluntary consent form for the funding source in client record. The facility confirmed billing occurred.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from March 14, 2025 licensing inspection.
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Plan of Correction
Pertaining to regulation 709.28 (c):
Client #3 Clinical Supervisor re-educated Admissions Representative on 4/8/2026 about the regulation and that consent form must be signed upon admission.
Clients #4,5,6,7 HR Director and Project Director discovered the consent form for funding sources in Sunwave EMR did not have the funding source section as a fillable option, therefore resulted in this section being left blank. HR Director contacted Sunwave EMR and the form has been corrected 4/9/2026. Clinical Supervisor re-educated intake staff about ensuring all sections of form are completed. Clinical Supervisor and Admissions Representative will complete weekly audits on intake forms. Clinical Supervisor will review intake forms during weekly clinical audit to confirm continued compliance. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in client record which included the name of the person, agency, or organization to whom the disclosure is made in two out of seven records reviewed.
Client # 1 was admitted to the residential program on July 25, 2025 and was discharged on September 24, 2025. The record contained a consent to release information signed July 25, 2025, that was missing the name of the person, agency, or organization to whom the disclosure is made.
Client # 2 was admitted on December 12, 2025 and discharged on January 3, 2026. The record contained a consent to release information form signed December 12, 2025, that was missing the name of the person, agency, or organization to whom the disclosure is made.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from March 14, 2025, licensing inspection.
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Plan of Correction
Pertaining to regulation 709.28 (c):
Clinical Supervisor re-educated Admissions Representative on 4/8/2026 about the regulation and that consent form must be signed upon admission.
Clients #1, 2 HR Director and Project Director discovered the consent form for funding sources in Sunwave EMR did not have the funding source section as a fillable option, therefore resulted in this section being left blank. HR Director contacted Sunwave EMR and the form has been corrected 4/9/2026. Clinical Supervisor re-educated intake staff about ensuring all sections of form are completed. Clinical Supervisor and Admissions Representative will complete weekly audits on intake forms. Clinical Supervisor will review intake forms during weekly clinical audit to confirm continued compliance. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by the client that they had been notified of their right that the project may not discriminate in the provision of services on the basis of creed, sex, color, national origin, sexual orientation, and religion in seven of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
HR Director contacted Sunwave EMR on to have the Clients Rights acknowledgment form corrected to reflect the company policy referencing that the project may not discriminate in the provision of services on the basis of creed, sex, color, national origin, sexual orientation, and religion. Sunwave EMR confirmed the form had been corrected 4/10/2026. |
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 three out of six applicable records reviewed.
Client #1 was admitted on July 25, 2025 and was discharged September 24, 2025. Client #1 was prescribed Bup-Nalox film 8 two times a day; however, there was no documentation that the client received or refused this medication July 26, 2025, July 27, 2025, and July 28, 2025.
Client #2 was admitted on December 12, 2025 and was discharged January 3, 2026. Client #2 was prescribed Olanzapine 5 mg once daily; however, there was no documentation that the client received or refused this medication on December 17, 2025, December 19, 2025, December 20, 2025, December 31, 2025, and January 3, 2026.
Client #4 was admitted on January 19, 2026 and was discharged on March 21, 2026. Client #4 was prescribed Metformin ER 750mg once daily; however, there was no documentation that the client received or refused this medication on January 25, 2026, January 26, 2026, January 27, 2026, January 28, 2026, January 29, 2026, January 30, 2026, and January 31, 2026.
Client #4 was prescribed Esomeprazole 40 mg once daily; however, there was no documentation that the client received or refused the medication on January 29, 2026, January 30, 2026, and January 31, 2026.
Client #4 was prescribed Bupropion HCL XL 300mg once daily; however, there was no documentation that the client received or refused this medication on February 3, 2026, February 4, 2026, February 6, 2026, February 11, 2026, February 12, 2026, and February 27, 2026.
Client #4 was prescribed Bupropion XL 150 mg once daily; however, there was no documentation that the client received or refused this medication on February 3, 2026, February 4, 2026, February 6, 2026, February 11, 2026, February 12, 2026, and February 27, 2026.
Client #4 was prescribed Lamotrigine 25 mg once daily; however, there was no documentation that the client received or refused this medication on February 1, 2026, February 2, 2026, February 3, 2026, February 4, 2026, and February 5, 2026.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from March 14, 2025, licensing inspection.
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Plan of Correction
Clinical Supervisor re-educated staff on proper medication protocol as per company policy. Clinical Supervisor will be auditing the med cart weekly. All meds are counted nightly, if there is a discrepancy in med counts, clinical supervisor will be notified. Any missed med doses will b documented on "missed medication log." Admissions Representative will review medication binder daily. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, that included progress notes completed within five days of a session that may be done either once per week or per individual session, per facility policy, in three of seven records reviewed.
Client #3 was admitted to the residential level of care on August 14, 2025 and was discharged November 14, 2025. The record contained progress notes for individual sessions occurring on August 19, 2025, August 29, 2025, September 4, 2025, September 12, 2025, September 17, 2025, September 26, 2025, October 1, 2025, October 9, 2025, October 15, 2025, and October 22, 2025, that were not documented until November 5, 2025.
Client #4 was admitted to the residential level of care on January 19, 2026 and was discharged March 21, 2026. The record contained a multi-session progress note for individual sessions occurring the week ending February 20, 2025, that was not documented until March 9, 2025.
Client # 7 was admitted to the residential level of care on January 29, 2026 and was active at the time of the licensing inspection. The record contained multi-session progress notes for individual sessions occurring during the weeks ending February 6, 2026, February 13, 2026, February 27, 2026, March 6, 2026, March 13, 2026, that were not documented until March 30, 2026. In addition, multi-session progress notes for individual sessions occurring during the weeks ending March 20, 2026, and March 27, 2026, were not documented until April 6, 2026.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor re-educated counselor on 4/8/2026 regarding clinical documentation policy and timeframes to complete weekly progress notes during monthly supervision meeting. Clinical Supervisor will conduct weekly chart audit to verify progress notes are submitted once per week per company policy. |
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 on an individual which included information relative to the client's involvement with the project, including follow-up information within 7 days and 30 days, per facility policy, in one of three applicable records reviewed.
Client #4 was admitted on January 19, 2026 and was discharged on March 21, 2026. There was no follow-up information documented in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor re-educated CRS' on policy pertaining to 7 and 30 day follow ups. CRSS is conducting weekly audit to confirm compliance with follow ups. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in six out of six applicable records reviewed.
Client # 1 was admitted to the residential program on July 25, 2025 and was discharged on September 24, 2025. The individual treatment and rehabilitation plan completed on August 1, 2025, did not include verification that work done by the client at the project was an integral part of treatment; however, documentation posted in common area contained evidence that clients were required to do work at the facility.
Client # 3 was admitted to the residential level of care on August 14, 2025 and was discharged on November 14, 2025.The individual treatment and rehabilitation plan completed on August 27, 2025, did not include verification that work done by the client at the project was an integral part of treatment; however, documentation posted in common area contained evidence that clients were required to do work at the facility.
Client # 4 was admitted to the residential level of care on January 19, 2026 and was discharged on March 21, 2026. The individual treatment and rehabilitation plan completed on February 11, 2026, did not include verification that work done by the client at the project was an integral part of treatment; however, documentation posted in common area contained evidence that clients were required to do work at the facility.
Client # 5 was admitted to the residential level of care on January 23, 2026 and was active at the time of the licensing inspection. The individual treatment and rehabilitation plan completed on January 29, 2026, did not include verification that work done by the client at the project was an integral part of treatment; however, documentation posted in common area contained evidence that clients were required to do work at the facility.
Client # 6 was admitted to the residential level of care on February 18, 2026 and was active at the time of the licensing inspection. The individual treatment and rehabilitation plan completed on February 20, 2026, did not include verification that work done by the client at the project was an integral part of treatment; however, documentation posted in common area contained evidence that clients were required to do work at the facility.
Client # 7 was admitted to the residential level of care on January 29, 2026 and was active at the time of the licensing inspection. The individual treatment and rehabilitation plan completed on February 3, 2026, did not include verification that work done by the client at the project was an integral part of treatment; however, documentation posted in common area contained evidence that clients were required to do work at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor contacted Sunwave EMR on 4/28/26 to have treatment plan updated to include life skills specific to their personal responsibilities at the facility, including specified chores that relate to their personal space. The treatment plan form was updated on 4/29/26 in the EMR. Clinical Supervisor re-educated counselor on treatment plan requirements on 4/29/26. All active treatment plans will be completely updated on 5/4/26 and Clinical Supervisor will audit all treatment plans weekly to ensure they have all of the required information. |