INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 1, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Diocese of Harrisburg, PA, Inc 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:
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and review of the personnel records, the facility failed to ensure that a written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor. Five out of five employee files reviewed the training plans were not signed or not dated or not completed for the current training year.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 11, 2025.
|
Plan of Correction
Each year in June Evergreen staff participate in their annual performance evaluations. The Director is responsible for the administration of all the performance evaluations. A part of each evaluation process training goals is created for the next year. All staff will have an updated training plan, and all will be completed by the end of September 2026. All new employees will have their initial training plan created during their 30-day evaluation completed by the program director and be evaluated annually in June. All training plans will be reviewed monthly to ensure completion. |
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.
|
Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
At the end of the calendar year, the policies and procedure will be reviewed by the Program Director and updated as appropriate. All staff will be provided with the updated policies and procedures at the January staff meeting for review. The annual updated and written manual were signed and placed in the facilities policy and procedure manual and is kept on the premises of Evergreen House. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states that the follow-up must be completed 30 days following discharge.
Client #5 was admitted on January 26, 2025 and was discharged on July 28, 2026. No follow-up was competed.
Client #6 was admitted on March 26, 2026 and was discharged on April 22, 2026. No follow-up was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The following procedure will be implemented to address the failed documentation of follow-ups on clients. 30 days post discharge a follow up call will be made and documented in the chart. 3 months later another call will be made and also documented. One year after a successful completion the final call will be made and documented in the chart. The facility director will be responsible to verify this procedure after each contact is made. |