INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19, 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(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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in one out of three employee records reviewed.Employee #2 was hired on September 9, 2024 as a counselor and was still in the position as of the date of the inspection. There was no training plan documented.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Each year during June/July Evergreen staff participate in their annual performance evaluations. The program director is responsible for the administration of all the performance evaluations. As a part of each performance evaluation process training goals are created for the next year. All current staff will have an updated training plan create upon completion of the performance evaluations. All training plans will be done by the program director and they will be completed by the end of August 2025.
New employees will have their initial training plan created during their 30 day evaluation by the program director and be evaluated yearly at the annual performance evaluation period June/July.
Copies of training plans will be submitted to HR for inclusion in the personnel files. The program director will review quarterly progress on training plan progress for resident assistants and CRS. Training progress will be reviewed monthly with counselors during supervisions. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical site inspection, it was determined that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. Fire extinguishers located in the hallways of sleeping area, and main floor common area did not have a current inspection tag. They were last inspected on May, 2024.This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
KINT is scheduled to inspect and update the fire extinguishers on June 25, 2025. One of our maintenance staff is scheduled to meet with the KINT staff to ensure that all the fire extinguishers are inspected and updated. The program director will monitor the fire extinguishers by adding a to do tickler yearly for late May and notify the landlord that they need to be inspected before June 25 of each year. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from July, 2024 through June, 2025 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on August 31, 2024 and then not again until April 12, 2025This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
We created a yearly fire drill schedule that documents the various times of day when we should hold the fire drill for that particular month. For 2025, we have scheduled overnight fire drills in April, August and October. Staff will be trained that work overnight shifts that the Fire drills should be held between the hours of 2 am and 4 am. Resident Attendants are responsible for executing the fire drills each month and they conduct the fire drill unannounced to clients or other staff. The schedule for the year already notes who is responsible. At every staff meeting, the program director will remind the designated staff they are responsible to hold a fire drill and the time of day. The program director will check half way through the month to determine if it was conducted yet and if not provide reminders to staff as appropriate to ensure that the fire drill occurs. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. There was a camera in the group counseling room.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Immediately upon learning about this citation, the program director placed a request to DDAP for a waiver for this requirement. On 6/20/25, the program director met with both of our counselors and advised them that all group counseling sessions must be held in the group room where there is no camera until we know if the wavier is approved. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of eight client records, the facility failed to document that all work done by clients at the project is an integral part of his treatment and rehabilitation plan in all eight client records. Client #1 was admitted on December 20, 2025 and was still active at the time of the inspection.Client #2 was admitted on March 27, 2025 and was still active at the time of the inspection.Client #3 was admitted on April 7, 2025 and was still active at the time of the inspection.Client #4 was admitted on April 22, 2025 and was still active at the time of the inspection.Client #5 was admitted on March 13, 2025 and was discharged on March 18, 2025.Client #6 was admitted on October 29, 2024 and discharged on March 18, 2025.Client #7 was admitted on May 18, 2025 and discharged on June 12, 2025.Client #8 was admitted on December 23, 2024 and discharged on June 16, 2025. This finding was discussed with facility staff during the inspection process.This is a repeat citation from the July 15, 2024 licensing inspection.
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Plan of Correction
The program director met with the counselors on 6/20/25 to discuss how to incorporate work, chores and following rules of accountability into treatment work. It was explained to them that all treatment plans must include goals related to work around the program and how that is critical to their recovery and developing accountability and life skills. We are meeting again on 6/27/25 to discuss the language we would like to use for treatment plans. We will work together to develop the language that captures the goal. All current clients will have this goal added to their treatment plans by 7/18/25. The program director will check all treatment plans by 7/30/25 to ensure work related goals are on the plans. New admissions will have this goal as a part of their treatment plans when they are initially developed. The program director will check treatment plans for clients moving forward when signing the plans. |