INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cathy ' s Hope 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log, the facility failed to conduct fire drills at least once a month.
The fire drill log was reviewed from January 2026 through July 2026. It was indicated in the fire drill log that no fire drill was completed for March 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Upon discovery of the deficiency, the required monthly fire drill was completed immediately. Moving forward, the Administrator will be responsible for ensuring completion of monthly fire drills in accordance with facility policy and regulatory requirements.
The Administrator will maintain the fire drill log and review documentation after each drill to ensure all required information is complete. Any missed drills or identified concerns will be addressed immediately. Fire drill records will also be reviewed weekly as part of the facility's ongoing quality assurance process by the Administrator to ensure continued compliance and prevent recurrence. |
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 and staff interview, the facility 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 applicable records.
Client #6 was admitted to the inpatient level of care on February 11, 2026 and was discharged July 20, 2026. Staff confirmed that information had been shared with the funder for Client #6, however, the facility did not obtain informed and voluntary consent to do so.
Client #7 was admitted to the inpatient level of care on February 11, 2026 and was discharged July 6, 2026. Staff confirmed that information had been shared with the funder for Client #7, however, the facility did not obtain informed and voluntary consent to do so.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The two identified clients were admitted prior to the effective date of the funding contract. Since implementation of funding contracts, Cathy's Hope has incorporated verification of informed and voluntary consent for funding sources into the admission process. Clinical Director will conduct montly chart audits to ensure ongoing compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in three of seven applicable records.
Client #2 was admitted to the inpatient level of care on May 6, 2026 and was active at the time of review. Client #2 had a treatment plan completed July 1, 2026. The next treatment plan update was due to be completed no later than July 31, 2026, however the next treatment plan update was completed August 4, 2026.
Client #5 was admitted to the inpatient level of care on April 30, 2026 and was discharged August 2, 2026. Client #5 had a treatment plan completed May 22, 2026. The next treatment plan update was due to be completed no later than June 21, 2026, however the next treatment plan update was completed July 2, 2026.
Client #7 was admitted to the inpatient level of care on February 11, 2026 and was discharged July 6, 2026. Client #7 had a treatment plan completed May 4, 2026. The next treatment plan update was due to be completed no later than June 3, 2026, however the next treatment plan update was completed June 11, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Cathy's Hope has implemented a treatment plan tracking system to monitor all 30 day treatment plan updates. Clinical staff were re-educated regarding the requirement, and the Clinical Director will review upcoming due dates weekly. Monthly chart audits will be conducted to ensure treatment plans are completed within the required timeframe. |