INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Evolution Counseling Services, 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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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 seven client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information in one of the seven records reviewed. Client #6 was admitted on October 02, 2025, and discharged February 27, 2026. There was documentation of disclosed to a funding source on October 02, 2025; however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.This finding was reviewed with facility staff during the inspection process.
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Plan of Correction
L0276: Project Director will start assisting the clinician in prepping the intake packets and highlight areas where signatures are needing to be obtain from the client, such as: client requesting a copy of the release, location of signature and date of signature.
With a failure to receive signatures on informed and voluntary consent forms, The Project Director will also review all recently completed intakes. The Project Director will review the recent intakes that are charted in the file to ensure that signatures are obtained and done so in a timely manner. The Project Director will also make sure that any clients who asked for copies of the documentation are provided those materials, and it is documented in the session in which the documentation was handed over.
Assisting in prepping intakes and reviewing opening clients and their intake documentation will take effect as quickly as March 13th, 2026. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of seven client records reviewed. Client #3 was admitted on August 08, 2025, and was active at the time of the inspection. A consent form signed and dated August 08, 2025, did not have documentation that the client was offered a copy of the consent form. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0289: With multiple clients not receiving copies of consent forms, the Project Director will increase the frequency of chart reviews from quarterly to bimonthly; with a focus on new and closing client charts. This allows the clinician to have additional oversight on the charts and have ample time to obtain signatures and document any attempts at obtaining signatures or having provided copies of documentation.
It should be noted that the active client (client 3) was offered a copy of the consent form and it was documented in the file his decline/approval of the consent form.
The frequency of bimonthly chart reviews will take place starting May 2026, but a conversation and implementation guide regarding the file reviews occurred with the clinician on 3/13/2026. |