INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2026, 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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704.11(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 document the completion of 25 clock hours of annual training for counselors for the facility training year of July 2025 - June 2026 in one out of three applicable records reviewed
Employee #2 was hired as a counselor on May 5, 2025, and was still in that position at the time of inspection. Employee #2 's personnel record only documented 17 clock hours of training for the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
According to code 704.11(f)(2), all counselors must have a certain amount of documented trainings hours per year. For this observation it was 25 hours.
Steps:
Executive/Clinical Director to ensure that each counselor has the correct amount of documented and completion of clocked hours for annual training every year.
Employee #2 will obtain the required 25 hours for the new training year and moving forward.
Executive/Clinical Director to track training hours for each counselor every 2 months (system within each individuals personnel file) to ensure hours are being completed. If training hours are not being completed in a timely fashion when track check occurs, Executive/Clinical Director and counselor will have a conversation and come up with a plan to make sure the hours are completed. This will allow for the deficiency not to reoccur again.
The Executive/Clinical Director is responsible for ensuring this corrective action is implemented and being completed.
Date in which the corrective action will be completed is on 8/5/2026.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment and document the instruction in two out of two applicable records reviewed.
Employee #4 was hired on November 10, 2025, as a counselor and was still in that position at the time of inspection. There was no documentation in the personnel record that the training was completed.
Employee #7 was hired on October 21, 2025 as a support staff and was still in that position at the time of inspection. There was no documentation in the personnel record that the training was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
According to code 705.28(c)(4), all personnel staff must be instructed/trained on the use of the fire extinguishers within the facility and to be documented within their personnel record.
Steps:
Executive Director to ensure all personnel staff are instructed and trained on the use of the fire extinguishers within the facility and it is documented within their personnel record to show that the instruction/training was completed upon hire.
The Executive Director updated Evolve's fire/emergency training employee form to reflect that this added instruction is within the form.
For active staff listed, they have been trained and instructed on the use of the fire extinguishers. The employee form stating this has been signed and place in the employee's personnel file.
The Executive Director and employees are responsible for ensuring this corrective action was implemented and completed and does not reoccur again.
Date in which the corrective action will be completed is on 08/05/2026.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative documents and a review of the project ' s website, the project failed to make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders.
The 2025 Annual Report was made publicly available on the facility ' s website but does not include a statement disclosing the names of officers, directors, or principal shareholders.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
According to code 709.22(c), within a facility's annual report it must state/show a statement of whom in which is part of the facility's governing body.
Steps:
The Executive Director has fixed the annual report on Evolve's website to state/show whom is part of Evolve's governing body. This is available to the public. The website below will show the change:
https://www.evolveaddictionrecovery.com/2025-ddap-statistics
To reflect that this does not reoccur, the Executive Director updates the annual report on a yearly basis and it will continue to include the governing body and any changes if applicable.
The Executive Director was responsible for ensuring this corrective action was implemented and completed.
Date in which the corrective action was completed was on 08/05/2026.
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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 contained in the client record in one out of seven records reviewed.
Client #7 was admitted on May 21, 2026, and was still active at the time of inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
According to code 709.28(c), the facility must obtain an informed and voluntary consent for the funding sources in which to be billed for an individuals services.
Steps:
Counselors/clinical staff will be trained by 7/30/2026 by the Clinical Director on their role and responsibility of this correction plan as follows. The Clinical Director is responsible for ensuring that the clinical staff are educated on this below.
Counselor responsible to obtain a written consent for the release of information from Client #7 for billing purposes to the funding source by 7/30/2026. Billing submission was paused for this record and audit existing claims sent to the funding source to determine necessary administrative reconciliation until release was signed.
Clinical Director to conduct a 100% audit of all active client records each week for all newly admitted clients to verify that valid, voluntary consent for information disclosure (including funding/insurance billing) is present and fully documented in every file.
Clinical Director and counselors to keep a census with active clientele that shows if they are still active after being in treatment for a year all appropriate consents are updated prior to that year mark. Clinical Director to ensure counselors are making these updates.
The Clinical Director as well as the counseling staff are responsible for ensuring this corrective action is implemented, completed, and does not reoccur.
Date in which the corrective action will be completed is on 07/30/2026.
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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 a decision to involuntarily terminate the client's treatment at the project in one out of one applicable record reviewed.
Client #4 was admitted on January 19, 2026, and discharged on February 11, 2026. There was no documentation in the client record that the facility notified the client in writing of the decision to terminate the client ' s treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
According to code 709.33, 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.
Steps:
Client #4's record was immediately audited. A formal, retroactive written notice of involuntary termination, including the rationale was prepared and sent via mail to Client #4's last known address. The letter was uploaded in Client #4's client record.
The Clinical Director will audit 100% of involuntary discharge records weekly for the next 90 days to ensure full compliance with written notification mandates. After 90 days, if 100% compliance is maintained, sampling will transition to monthly audits of all discharge files by the Clinical Director, with findings being reported to the clinical staff if applicable.
The Clinical Director is responsible for ensuring this corrective action is implemented and completed.
Correction action plan was implemented on 08/05/2026 and is ongoing.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #2 was admitted on July 15, 2025, and was discharged on February 4, 2026. The treatment plan dated August 20, 2025, indicated group sessions one time per week and individual sessions one time biweekly. There was no documentation of group sessions during the weeks of September 28 - October 4, 2025, October 12-18, 2025, November 23-29, 2025, December 21-27, 2025, or December 28, 2025 - January 3, 2026. There was no documentation of individual sessions during the week of December 28, 2025 - January 3, 2026.
Client #3 was admitted on November 10, 2025, and was discharged on March 18, 2026. The treatment plan dated November 10, 2025, indicated group sessions four times per week and individual sessions once per week. Only three group sessions were documented during the week of November 30 - December 6, 2025.
Client #4 was admitted on January 19, 2026, and was discharged on February 11, 2026. The treatment plan dated January 19, 2026, indicated group sessions four times per week and individual sessions once per week. There was no documentation of any individual sessions during the weeks of January 25-31, 2026 or February 1-7, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
According to code 709.92(c), the project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
The Clinical Director and counselor staff will ensure that the frequency of scheduled appointments are documented within the client's treatment record and if there is a reason for a client to not be following their treatment plan frequency then a case consult/note will be documented to show reasoning for stated change in frequency.
Steps:
For all active clients currently receiving services, counselors conducted an immediate audit to compare individual treatment plan service frequency requirements against actual clinical documentation, ensuring no current gaps exist.
A comprehensive 100% audit of all active client records will be conducted by each counselor and their caseload on a bi-weekly basis to identify any discrepancies between prescribed counseling frequencies (individual and group) and actual session documentation.
Any identified service gaps or missing documentation will be flagged immediately for corrective action and follow-up with clinical oversight.
Findings from bi-weekly audits will be presented to the Clinical Director to ensure sustained compliance and to ensure this citation does not occur again.
Correction action was implemented on 8/5/2026 and will remain ongoing.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to provide a complete client record on an individual, to include information relative to the client ' s involvement with the project, including case consultations within 60 days of the development of the master treatment plan and with the development of each subsequent treatment plan update, per facility policy, in two out of six applicable records reviewed.
Client #2 was admitted on July 15, 2025, and discharged on February 4, 2026. A case consultation was to be completed at the time of the treatment plan update on October 21, 2025; however, there was no documentation that one was completed.
Client #5 was admitted on April 16, 2026, and was active at the time of inspection. A case consultation was due to be completed by June 15, 2026; however; there was no documentation one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Evolve Addiction Recovery's policy and procedure stated that a corresponding case consultation is created with each subsequent treatment plan to summarize the plan and the client's goals (created by the client's primary counselor on the same day as the treatment plan update).
The policy and procedure for code 709.24 in which this reflects and brings on this citation, has been changed/updated by Evolve Addiction Recovery's Executive/Clinical Director to reflect that case consultations do not have a specific timeframe of being completed; rather when and if applicable for reasons such as risk/safety concerns, when supervision of an individuals clinical chart is reviewed with the Clinical Director, counselor, and/or medical team, transfers of care or referrals, legal requests, any scope of practice dilemmas, etc. Case consultations may be completed at the time of a treatment plan update; however, does not have to be.
The Executive/Clinical Director was responsible for ensuring this corrective action was implemented and completed. The Executive/Clinical Director was responsible for and will be responsible for educating the staff on the policy/procedure change. Current staff was trained and educated as of 8/19/2026.
Date in which the corrective action was completed was on 8/19/2026. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual, to include an aftercare plan starting at the time of intake and completed on the day of discharge, per facility policy, in two out of three applicable records reviewed.
Client #2 was admitted on July 15, 2025, and discharged on February 4, 2026. There was no documentation that aftercare planning was completed by the date of discharge.
Client #4 was admitted on January 19, 2026, and discharged on February 11, 2026. There was no documentation that an aftercare plan was started at intake.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Evolve Addiction Recovery's policies and procedures for 709.24 and 709.94 in regard to aftercare planning have been updated to reflect new documentation implementation for aftercare planning by the Executive/Clinical Director to ensure aftercare planning is documented correctly for clients moving forward. The old policy/procedure for aftercare planning did not reflect on how aftercare planning should be executed correctly based of the citations given.
The Executive/Clinical Director has reached out to their EMR/EHR system to make changes within the treatment plans as well as the discharge summary to show better aftercare planning communication and documentation so citations in this matter do not reoccur.
Correction action plan will be fulling implemented as of 10/02/2026 and policy changes to be completely executed after other office licensing audits to ensure all offices are aware of the change and added documentation (10/02/2026).
Clinical Director will also audit 100% of discharged client records weekly for 90 days after full implementation to ensure full compliance with aftercare plan initiation and completion dates. If 100% compliance is maintained after 90 days, audit frequency may decrease to a random sample of discharged charts monthly. This will ensure ongoing oversight and immediate corrective measures if non-compliance reoccurs.
The Executive/Clinical Director is responsible for ensuring this corrective action will be implemented and completed. The Executive/Clinical Director is responsible for and will be responsible for educating the staff on the policy/procedure change. Current staff will trained and educated as of 10/02/2026.
Date in which the corrective action will be completed is 10/02/2026. |
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 a review of client records, the facility failed to provide a complete client record on an individual, to include information relative to the client's involvement with the project, including a discharge summary completed within seven business days of discharge, per facility policy, in two out of four applicable records reviewed.
Client #3 was admitted November 10, 2025, and was discharged on March 18, 2026. A discharge summary was due no later than March 27, 2026; however, it was not documented until June 20, 2026.
Client #4 was admitted on January 19, 2026, and was discharged on February 11, 2026. A discharge summary was due no later than February 20, 2026; however, it was not documented until April 9, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
According to code 709.93(a)(10) 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 a discharge summary.
Steps:
Mandatory re-education on facility record-keeping policies?specifically the mandate requiring discharge summaries to be completed within seven (7) business days?will be conducted for all clinical and administrative staff by the Clinical Director.
Clinical Director and counselors will now review the discharge census during weekly in-house census meetings to ensure there is a discharge summary completed within seven business days of discharge according to Evolve's policy.
There will be ongoing auditing of this done by the Clinical Director to ensure this citation is not reoccurring.
Date in which the corrective action will be completed is on 08/05/2026.
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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 a review of client records, the facility failed to provide a complete client record on an individual, to include information relative to the client's involvement with the project, including follow-up information completed 30 days after discharge, per facility policy, in three out of three applicable records reviewed.
Client #1 was admitted on January 6, 2026, and discharged on March 25, 2026. A follow up was due no later than April 24, 2026; however, there was no documentation that one was completed.
Client #2 was admitted on July 15, 2025, and discharged on February 4, 2026. A follow up was due no later than March 6, 2026; however, there was no documentation that one was completed.
Client #4 was admitted on January 19, 2026, and discharged on February 11, 2026. A follow up was due no later than March 13, 2026; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
According to code 709.93(a)(11) 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: Follow-up information.
Steps:
A full audit of all clients discharged within the last 60 days will be conducted by the Clinical Director to identify and resolve any additional missing 30-day follow-up assessments.
All clinical and case management personnel will undergo mandatory retraining on facility policy regarding discharge protocol, emphasizing the requirement to document follow-up attempts or completions within 30 days of release.
The Clinical Director will audit 100% of discharged client records weekly for the next 90 days to ensure 30-day follow-ups are completed and documented on time. If 100% compliance is sustained after 90 days, audits will transition to a random sampling of discharged files. Any discrepancies there after would be addressed.
Date in which the corrective action will be implemented is on 8/5/26 and is ongoing.
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