INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 3, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Evolve Addiction Recovery LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that one counselor met the educational qualifications for the position in one of three applicable records reviewed.
Employee #3 was hired as a counselor assistant on July 1, 2024 then promoted to counselor on July 1, 2025 and was currently employed in this position at the time of licensing process; however, this employee does not possess a qualifying degree from an accredited college, nor a full certification as an addiction counselor by a statewide certification body to meet the qualifications to be promoted to counselor.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Employee #3 was put back to counselor assistant status immediately after review. Employee #3 will be taking the CADC test once qualifies to take said test, which will be in July of 2026. Once test is complete and passed, Employee #3 will then qualify for counselor status.
Responsible for Employee #3 being put back down to counselor assistant status was by the Executive/Clinical Director as of 10/4/2025. The Executive/Clinical Director will also be responsible for Employee #3 to take the CADC test to meet qualifications prior to moving to counselor status. |
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 the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable client records reviewed.
Client #4 was admitted on March 19, 2025 and was involuntarily discharged on September 4, 2025. It was not documented in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
According to Evolve Addiction Recovery's discharge policy and procedure as well as DDAP's policy; a client must be notified in writing, of a decision to involuntarily terminate the client's treatment. Client #4 was sent a letter that explained their involuntarily termination as of 9/4/2025 and has been documented in their chart as of 10/10/2025. The project will assure that each client upon discharge (regardless of type) will receive in writing of their discharge.
Response for action: Executive/Clinical Director to assure that clinicians are including written notices to clients of their discharge at the time of their discharge and documenting it within their chart. Action date and moving forward as of 10/10/2025. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of outpatient client records, the facility failed to follow the facility ' s intake procedures that included documentation of psychosocial evaluation within seven days of intake in six of seven records reviewed.
Client #2 was admitted to the outpatient program on January 30, 2025 and discharged on August 25, 2025. A psychosocial evaluation was not documented until March 19, 2025.
Client #3 was admitted to the outpatient program on January 28, 2025 and discharged on May 15, 2025. A psychosocial evaluation was not documented until February 13, 2025.
Client #4 was admitted to the outpatient program on March 19, 2025 and discharged on September 4, 2025. A psychosocial evaluation was not documented until April 7, 2025.
Client #5 was admitted to the outpatient program on February 26, 2025 and was active at the time of the licensing inspection. A psychosocial evaluation had been started, however was not completed in client chart at time of licensing process.
Client #6 was admitted to the outpatient program on July 2, 2025 and was active at the time of the licensing inspection. A psychosocial evaluation was not documented until July 14, 2025.
Client #7 was admitted to the outpatient program on May 22, 2025 and was active at the time of the licensing inspection. A psychosocial evaluation was not documented until July 28, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Evolve Addiction Recovery's policy and procedure stated that documentation of the biopsychosocial to be completed and signed on the same day of when the biopsychological was performed/completed with the client. The policy and procedure for code 709.24 in which this reflects, has been changed/updated by Evolve Addiction Recovery's Executive/Clinical Director to reflect that the documentation of the biopsychosocial to be completed and signed (by both the individual that performed the evaluation and the clinical supervisor/director) within 7 business days of when the biopsychosocial was performed/completed with the client.
The Executive/Clinical Director is responsible for ensuring this corrective action is implemented.
Date in which the corrective action was completed was on 8/29/2025 from previous office DDAP inspection. Implemented fully into this office was on 10/3/2025. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included a discharge summary within seven days of discharge, per facility policy, in four of four applicable client records reviewed.
Client #1 was admitted to the outpatient program on May 21, 2025 and discharged on August 14, 2025. A discharge summary was not documented until September 29, 2025.
Client #2 was admitted to the outpatient program on January 30, 2025 and discharged on August 25, 2025. A discharge summary was not documented until September 29, 2025.
Client #3 was admitted to the outpatient program on January 28, 2025 and discharged on May 15, 2025. A discharge summary was not documented until September 29, 2025.
Client #4 was admitted to the outpatient program on March 19, 2025 and discharged on September 4, 2025. A discharge summary was not documented until September 30, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
According to Evolve Addiction Recovery's policy and procedure for discharges, a discharge summary must be completed within 7 days of the individual's discharge.
Responsible for this action: Executive/Clinical Director is too assure that clinicians are completing their discharge paperwork/summaries within 7 days per the facility policy. The steps in which will be taken is to review discharges with each clinician on a weekly basis during census meetings/go over all required paperwork within the clients chart to assure the deficient doe not recur. Executive/Clinical Director to go over facilities policies and procedures with clinical staff again to assure everyone is aware what needs to be done in a timely manner. Date action was resolved: 10/6/2025 |
709.93(a)(11) LICENSURE Client records
709.93. 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 outpatient client records, the project failed to document a complete client record on an individual that included follow-up information within 30 days, per facility policy, in one of three applicable client records reviewed.
Client #3 was admitted to the outpatient program on January 28, 2025 and discharged on May 15, 2025. Follow up information was to be documented by June 14, 2025; however, it was not documented until September 29, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
According to Evolve Addiction Recovery's policy and procedure for discharges, a 30-day follow-up should be completed no later then 30 days after an individual's discharge.
Responsible for this action: Executive/Clinical Director is too assure that clinicians are completing their 30-day follow ups per the facility policy for individuals that have been discharged from treatment. Steps that will be taken are once a client is discharged regardless of type will be put on a 30-day follow up list that clinicians and Executive/Clinical Director will have access to. This list will be a tool for clinicians to do their 30-day follow-ups on time. Executive/Clinical Director to go over this list at each weekly census meeting to assure the deficiency does not reoccur.
Executive/Clinical Director to also go over facilities policies and procedures with clinical staff again to assure everyone is aware what needs to be done in a timely manner. Date action was resolved: 10/6/2025 |