INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare 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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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative information, the facility failed to document an assessment of staff training needs, per their policy, for the training year January 1, 2025, through December 31, 2025.
Facility policy and procedures state than an assessment of staff training needs is completed in December; however, it was completed June 23, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director has finalized and submitted the overdue 2025 assessment of training needs as of June 23, 2025, and ensured it is placed in the appropriate administrative file for reference and internal accountability. Automated calendar reminders have been created in the Project Director's and HR Manager's calendars to prompt development and approval of the assessment each year by December 31. The deficiency has been addressed retroactively with the submission of the 2025 plan. The procedural safeguard of automated reminders will be fully in place by August 1, 2025, ahead of the 2026 planning cycle |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative information, the facility failed to document an overall plan for addressing staff training needs, per their policy, for the training year January 1, 2025, through December 31, 2025.
Facility policy and procedures state than an overall training plan is completed in December; however, it was completed June 23, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director has finalized and submitted the overdue 2025 agency training plan as of June 23, 2025, and placed it in an administrative file for reference and internal accountability. Automated calendar reminders have been created in the Project Director's and HR Manager's calendars to prompt development and approval of the annual training plan each year by December 31. The deficiency has been addressed retroactively with the submission of the 2025 plan. The procedural safeguard of automated reminders will be fully in place by August 1, 2025, ahead of the 2026 planning cycle |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administrative information, the facility failed to collect feedback on completed trainings in one of three applicable personnel records.
Facility policy and procedures state feedback forms are to be completed within seven days of training.
The training year January 1, 2024, through December 31, 2024, was reviewed and feedback was not collected for any training.
Staff #1 was hired on March 1, 2010.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director has initiated a compliance review of all 2024 training records to identify and document any other missed feedback forms. Retrospective feedback documentation will be completed by Staff #1 and other applicable staff for all 2024 trainings, even if delayed. Training feedback forms will be collected by the Training Coordinator when staff submits training verification throughout the training year. Training feedback forms will be collected by the Training Coordinator for all in-house trainings. The HR Manager will ensure compliance with quarterly reviews of staff training files. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative information, the facility failed to document an evaluation of the overall training plan, per their policy, for the training year January 1, 2024, through December 31, 2024.
Facility policy and procedures state than an evaluation of the overall training plan for the previous training year is completed by January 31; however, it was completed June 23, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Freedom Healthcare Services acknowledges that the evaluation of the 2024 training year was not completed within the policy timeframe by January 31, 2025. To correct this deficiency, the Project Director has finalized and submitted the overdue 2025 evaluation pf the 2024 training plan as of June 23, 2025, and ensured it is placed in the appropriate administrative file for reference and internal accountability. To prevent recurrence, the facility has implemented automated calendar reminders in the Project Director's and HR Manager's calendars to prompt evaluation each year of the previous training year by January 31. The deficiency has been addressed retroactively with the submission of the 2025 plan. The procedural safeguard of automated reminders will be fully in place by August 1, 2025. |
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 administrative information, the facility failed to develop a written individual training plan for each employee, per their policy, in six of seven records.
Facility policy and procedures state than an individual training plan is to be developed for each employee annually in December, or within thirty days of hire.
Staff #1 was hired on March 1, 2010. There was no training plan for staff #1.
Staff #2 was hired on March 11, 2025. The training plan was developed June 13, 2025.
Staff #3 was hired on May 8, 2025. The training plan was developed June 24, 2025.
Staff #4 was hired on May 5, 2025. The training plan was developed June 23, 2025.
Staff #6 was hired on September 5, 2017. The training plan was developed January 7, 2025.
Staff #7 was hired on November 1, 2016. The training plan was developed June 20, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All identified staff members now have completed and signed ITPs on file, developed with their supervisors and tailored to their individual roles and skills. All outstanding ITPs were completed on June 23. 2025. A compliance note will be attached to each record acknowledging the documentation lapse and the corrective date. To prevent future ITP noncompliance, new hire onboarding procedures now require ITPs to be completed within 30 days and verified by HR with an onboarding checklist. Annual ITP completion is now a December action item with the Facility Director and HR Manager having calendar alerts set to indicate that ITPs are due by Dec 31. Supervisors will be retrained on ITP policy and deadlines during a supervisors meeting held July 30, 2025. Beginning October 2025, quarterly audits by HR Director will include ITP documentation checks. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the personnel training records, the facility failed to have the project director complete at least 12 clock hours of annual training in one of one record.
Staff #1 was hired as the project director on March 1, 2010. Staff #1 documented four hours of training for the January 1, 2024, through December 31, 2024, training year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
To ensure ongoing compliance a training log and tracker has been created to monitor annual clock hours for all leadership staff, with quarterly progress reviews beginning Q3 2025 by the HR Manager. An annual professional ITP will be completed for all directors during December, outlining target courses aligned with DDAP-approved topics. The HR Manager will provide quarterly reports beginning Q3 of 2025 of training hour status to the Project Director and Facility Director to ensure timely year-end completion of training requirements. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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 plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The last inspection was February 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Operations Manager ensured that an inspection and approval of the fire extinguishers was completed on June 30, 2025. Documentation of the inspected and approved fire extinguishers is on file with the Operations Manager. The Operations Manager has set calendar reminders as of July 2025 to alert staff of the yearly inspection due date. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of administrative information, the facility failed to ensure the personnel records included an annual written individual staff performance evaluation in two of three applicable records.
Facility policy and procedures states performance reviews are completed annually at beginning of calendar year.
Staff #1 was hired on March 1, 2010. There was no performance evaluation for calendar year beginning January 1, 2025.
Staff #6 was hired on September 5, 2017. There was no performance evaluation for calendar year beginning January 1, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Annual staff performance evaluations were not documented during the first quarter as required by facility policy. To correct this the HR department will maintain a Performance Evaluation Tracker, which now includes checkpoints and firm deadlines. Supervisors are required to schedule annual evaluations during Q1 each year, with follow-up confirmation submitted to HR by February 15. An automated reminder has been implemented to notify supervisors starting January 2 each year. Quarterly HR compliance audits will include performance evaluation status reviews beginning with Q3 2025. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in three of seven records.
Client #2 was admitted on October 30, 2024, and was still active at the time of the inspection. A treatment plan was completed on October 30, 2024, and an update was due no later than December 30, 2025; however, it was completed on February 4, 2025. The following update was completed March 20, 2025, and the next update was due May 5, 2025; however, there were no further updates in client #2 ' s record.
Client #3 was admitted on November 14, 2024, and was still active at the time of the inspection. A treatment plan update was completed on April 1, 2025, and the next update was due no later than June 1, 2025; however, it was completed on June 5, 2025.
Client #7 was admitted on August 12, 2024, and discharged on May 20, 2025. A treatment plan update was completed on March 6, 2025, and the next update was due no later than May 6,2025; however, it was completed on May 20, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 13, 2023, and June 12, 2024, licensing inspections.
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Plan of Correction
No staff involved in late entry of these treatment plans no longer work for FHS and cannot be involved in corrective measures. The Facility Director is implementing weekly chart monitoring by the Clinical Supervisor who will review a weekly report of all open upcoming or overdue treatment plans. The Clinical Supervisor will address upcoming and late treatment plans one on one with staff during supervision meetings. Starting October 2025, the Facility Director will initiate quarterly audits focused on documentation timelines for treatment plans, case consults, and progress notes. Clinical staff will receive retraining on treatment plan timelines during an August 2025 in-service session. Ongoing refreshers will be conducted during clinical supervision and during onboarding for all new clinical personnel. |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in two of six applicable records.
The facility's policy and procedures state a case consultation must be completed every 90 days following admission for the first year and then annually or as needed.
Client #2 was admitted on October 30, 2024, and was still active at the time of the inspection. A case consult was completed on January 28, 2025, and the next one was due no later than April 28, 2025; however, it was completed on May 28, 2025.
Client #3 was admitted on November 14, 2024, and was still active at the time of the inspection. A case consult was completed on February 12, 2025, and the next one was due no later than May 13, 2025; however, it was completed on May 14, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The staff involved in the late entry or missing case consults do not work for FHS any longer therefore they cannot participate in corrective action. The Facility Director is implementing weekly chart monitoring by the Clinical Supervisor who will review a weekly report of all open upcoming or overdue case consults. The Clinical Supervisor will address upcoming and late consults one on one with staff during supervision meetings. Starting October 2025, the Facility Director will initiate quarterly audits focused on documentation timelines for treatment plans, case consults, and progress notes. Clinical staff will receive retraining on case consult timelines during an August 2025 in-service session. Ongoing refreshers will be conducted during clinical supervision and during onboarding for all new clinical personnel. |