INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2025 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:
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to provide a sufficient number of staff persons trained in CPR and first aid, so that at least one person trained in these skills is onsite during the project's hours of operation.The facility did not have CPR/first aid coverage on July 21, July 28 and August 4, 2025 from 10pm - 11pm. In addition, there was no coverage on July 26 and 27, August 3 and 9, 2025 from midnight - 8am.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Any current staff who work shifts alone (primarily overnight shifts) and do not have their CPR/First Aid certification will be removed from the schedule until they have completed their certification.
The scheduler will be contacted by 9/18/2025 to have them removed off the schedule by the program director. Staff will be notified by the scheduler that they have been removed from the schedule and need to complete their CPR/First Aid to be added back on the schedule. Once the CPR/First Aid certification is received, then the program director will advise the scheduler they are able to be scheduled for shifts alone. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release information form to include name of the person, agency or organization to whom disclosure is made in one out of six records reviewed.Client #2 was admitted on September 3, 2025 and was still active at the time of the inspection. A release form dated September 3, 2025 without the required information.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon admission to Evergreen, all residents are provided a packet of information that includes a series of pre-populated releases to common referral sources for the agency. An un-populated release was included in the packet in this case that led to the citation.
Immediately, the RA will review the release packet and remove any un-populated releases. We will not have any residents sign an un-populated release.
At our next staff meeting scheduled for 9/24/25, all staff (Resident Assistants, counselors and CRS) will be trained by the program director on the proper completion of releases. (This did happen).
Additionally, since the counselors are primarily responsible for the completion of releases, during their clinical supervision which will be held on either 9/25 or 9/26/25, there will be additional training by the program director on the proper process for completing releases. (This happened on 9/26/25 during supervision).
The lead RA will check new charts within 2 weeks to ensure all releases as a result of admission are completed correctly and signed. The program director will check the chart within one month of admission to ensure all releases are completed correctly. The program director will continue to check charts monthly to ensure all releases are completed correctly. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of three applicable records reviewed. Client #1 was admitted on July 31, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on August 11, 2025, with no type or frequency identified. Client #4 was admitted on July 29, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on August 12, 2025, with no type or frequency identified. Client #6 was admitted on July 21, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on August 5, 2025, with no type or frequency identified. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon learning of this citation during the audit, immediate action was taken to correct it.
On 9/11/25, the program director met with the counselors to review the outcome of the audit. In this meeting they were informed of the need to include in all future treatment plans a detailed goal that outlines the expected types of treatment and frequency. Information to be included is the weekly counseling sessions, the weekly group sessions, the expectation of daily participation in 12-step meetings and the recommended frequency of outpatient counseling.
This additional treatment goal will begin with all new admissions; we have a new admission coming on 9/16/25 and will be added to all current client treatment plans when they are scheduled to be updated.
All treatment plans will reflect this goal by the end of October 2025. The program director will review all the treatment plan to ensure they reflect the goal by November 14th. |