Catalyst Residential Treatment Center

Out of compliance, unannounced, annual inspection : R501-1-8(1)(a)-(i) Facility and safety requirements

The provider was out of compliance with R501-1-8(1)(i) by not having prescription medication stored in its original pharmacy packaging. During the inspection, loose pills were found in clients’ medication folders and pill bottles’ labels had been removed. Technical assistance was previously provided for this rule on 10/21/2025. This rule noncompliance is a repeat noncompliance as noted on 12/28/2023, 02/29/2024, 03/25/2024, 05/30/2024, 06/25/2024, and 08/12/2024.

Out of compliance, follow-up inspection, non on-site inspection : R380-600-7(16)(a)-(e) Critical incidents reporting requirements

The provider was out of compliance with R380-600-7(16)(a) by not reporting all critical incidents to OL. By the due date set in the program’s plan of correction, 3/13/2026, not all missing critical incidents had been reported. This noncompliance is a repeat noncompliance as noted on 7/13/2023, 7/18/2023, 8/10/2023, 8/30/2023, 02/29/2024, 03/25/2024, 08/12/2024, 08/21/2024, and 2/10/2026. Technical assistance was provided for this rule on 10/21/2025.

Out of compliance, announced, annual inspection : R501-1-8(3) Medication and hazardous items maintenance and storage

The provider was out of compliance with R501-1-8(3) by not having medications not in active use in locked storage. During the inspection, aspirin and acetaminophen were found not in locked storage. This rule noncompliance is a repeat noncompliance as noted on 02/13/2023 and 07/13/2023. Technical assistance was previously provided for this rule on 10/21/2025.

Out of compliance, announced, annual inspection : R380-600-7(16)(a)-(e) Critical incidents reporting requirements

The provider was out of compliance with R380-600-7(16)(a) by not reporting critical incidents to OL. During the file review, all critical incidents that had occurred at the facility in the last 6 months had not been reported.This noncompliance is a repeat noncompliance as noted on 02/29/2024, 03/25/2024, 08/12/2024, and 08/21/2024. Technical assistance was previously provided for this rule on 10/21/2025.

Out of compliance, announced, annual inspection : R501-14-5(5)(a)-(b) Denied applicants may not direct access to clients

The provider was out of compliance with R501-14-5(5)(a) by having an employee working at the facility with a failed background check. During the inspection, an employee was found to be working at the facility who was not in DACs and had previously failed a background screening.

Out of compliance, follow-up inspection : R501-1-13(5)(a)-(b) Private placement reporting

The licensee was out of compliance with R501-1-13(5)(a)-(b) by not reporting private placements to the office by the fifth business day of each month. During the file review, the licensor observed that the provider had not reported on all months of the year. This rule non-compliance is a repeat non-compliance as noted on 02/13/2023, 02/29/2024, 03/25/2024, 2/26/2025, and 3/17/2025.

Out of compliance, follow-up inspection, non on-site inspection : R501-1-16(2)(a)-(q) Program policy and training

The licensee was out of compliance with R501-1-16(2)(a)-(q) by not having all employees trained annually on the required topics. During the file review, it was observed that some employees had not received each of the required annual trainings. This rule non-compliance is a repeat noncompliance as noted on 02/13/2023, 02/29/2024, 03/25/2024, and 2/26/2025.

Out of compliance, follow-up inspection, non on-site inspection : R501-1-16(1)(a)-(u) Pre-service training requirements

The licensee was out of compliance with R501-1-16(1)(a)-(u) by not ensuring all employees were trained on the required pre-service training topics within 30 days of hire. During the file review, not all employees had received the necessary pre-service trainings and were past 30 days of hire. This rule was previously found out of compliance on 2/26/2025.

Out of compliance, follow-up inspection, non on-site inspection : R501-1-13(5)(a)-(b) Private placement reporting

The licensee was out of compliance with R501-1-13(5)(a)-(b) by not reporting private placements to the office by the fifth business day of each month. During the file review, the licensor observed that the provider had not reported on all months of the year. This rule non-compliance is a repeat non-compliance as noted on 02/13/2023, 02/29/2024, 03/25/2024, and 2/26/2025.

Out of compliance, follow-up inspection, non on-site inspection : R501-1-13(1)(a)-(h) Intake assessment requirements

The licensee was out of compliance with R501-1-13(1)(a)-(h) by not having an intake assessment completed for each client surveyed with each of the required items. During the file review, the provider was unable to show that two clients surveyed had an intake assessment from the program, while a third client had an intake assessment that was missing information regarding gender identity and individualized assessment for bedroom and bathroom assignments, cultural background, and family history and dynamics. This rule non-compliance is a repeat non-compliance as noted on 02/29/2024 and 2/26/2025.

Out of compliance, follow-up inspection, non on-site inspection : R501-1-11(1)(a)-(o) Required client information

The licensee was out of compliance with R501-1-11(1)(a)-(o) by not asking identified gender information on intake paperwork and not having all critical incidents stored with clients’ files. During the file review, identified gender could not be found on the intake paperwork and a client file had a known critical incident involving the client that was not stored with it. This rule non-compliance is a repeat non-compliance as noted on 02/13/2023, 02/29/2024, and 2/26/2025.

Out of compliance, follow-up inspection, non on-site inspection : R501-1-10(5)(a)-(b) Documented safe food practices training

The licensee was out of compliance with R501-1-10(5)(a)-(b) by not having documentation of employee training on safe food practices. During the file review, the provider was unable to show a way employees had been trained on allowances for nutritious snacks and how to accommodate clients with special dietary needs. This rule was previously found out of compliance on 2/26/2025.

Out of compliance, announced, annual inspection : R501-1-16(2)(a)-(q) Program policy and training

The provider was out of compliance with R501-1-16(2)(a)-(q) by not having all employees trained annually on the required topics. During the file review, it was observed that some employees had not received each of the required annual trainings. This rule non-compliance is a repeat noncompliance as noted on 02/13/2023, 02/29/2024, and 03/25/2024.

Out of compliance, announced, annual inspection : R501-1-15(10)(a)-(f) Required personnel information

The provider was out of compliance with R501-1-15(10)(a)-(f) by not storing critical incidents with personnel files. During the file review, the provider had no way to show what critical incidents a given employee had been involved in. This rule non-compliance is a repeat non-compliance as noted on 02/13/2023.

Out of compliance, announced, annual inspection : R501-1-13(5)(a)-(b) Private placement reporting

The provider was out of compliance with R501-1-13(5)(a)-(b) by not reporting private placements to the office by the fifth business day of each month. During the file review, the licensor observed that the provider had not reported on all months of the year. This rule non-compliance is a repeat non-compliance as noted on 02/13/2023, 02/29/2024 and 03/25/2024.

Out of compliance, announced, annual inspection : R501-1-12(5)(a)-(d) Discharge plan resources

The provider was out of compliance with R501-1-12(5)(a)-(d) by not having a discharge plan completed for a client. During the file review, a client who had left the program over 30 days ago did not have a discharge plan. This rule non-compliance is a repeat non-compliance as noted on 02/13/2023 and 02/29/2024.

Out of compliance, announced, annual inspection : R501-1-11(1)(a)-(o) Required client information

The provider was out of compliance with R501-1-11(1)(a)-(o) by not asking identified gender information on intake paperwork and not having all critical incidents stored with clients’ files. During the file review, identified gender could not be found on the intake paperwork and a client file had a known critical incident involving the client that was not stored with it. This rule non-compliance is a repeat non-compliance as noted on 02/13/2023 and 02/29/2024.

Out of compliance, 2nd unannounced : R501-1-8(1)(a)-(i) Facility and safety requirements

The provider was out of compliance with the rule by not having all bathrooms stocked with hand soap, not having all prescription medication stored in its original pharmacy packaging, and not ensuring client health and safety regarding vehicle safety at the time of the inspection. This rule non-compliance is a repeat non-compliance.

Out of compliance, 2nd unannounced : R380-600-7(16)(a)-(d) Critical incidents reporting requirements

The provider was out of compliance with the rule by not reporting critical incidents to the office. During the inspection, client interviews revealed two critical incidents that had not been reported. This rule non-compliance is a repeat non-compliance.