INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Forge Health 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's November 2024 through September 2025 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's hours of operation were posted as Monday, Tuesday and Thursday from 9:00AM to 8:30PM, and Wednesday, Friday from 9:00AM to 5:00PM. During the reviewed period, all the fire drills conducted were completed between 2:00PM and 3:05PM. There was no documentation indicating fire drills were conducted during the facility's morning or evening hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will hold the fire drills at different days of the week, and at different times throughout the day, including the first, second, and third shifts. The fire drills will continue to occur monthly, and all staff in the office at the time of the drill will continue to participate in the fire drill. The Clinical Director will continue to complete the Fire Drill Log after drill is held. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a review of client records, the facility failed to ensure individual treatment and rehabilitation plans were developed with the client and completed within the timeframes prescribed in the facility policy in three of seven client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed after the first session.
Client # 2 was admitted on July 28, 2025 and was still active at the time of the inspection. There was an August 7, 2025 draft of an individual treatment and rehabilitation plan documented in the client record; however, the plan was not completed and signed by the client or the counselor.
Client # 3 was admitted on August 15, 2025 and was still active at the time of the inspection. The first session was dated September 9, 2025 and the individual treatment and rehabilitation plan was due to be completed at that time; however, the plan was not completed until September 19, 2025.
Client # 6 was admitted on January 22, 2025 and was discharged on August 26, 2025. The first session was dated February 5, 2025 and the individual treatment and rehabilitation plan was due to be completed at that time; however, the plan was not completed until February 19, 2025.
This is a repeat citation from the October 15, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be given to clinical staff during onboarding upon hire and ongoing within the clinic in order to identify and appropriately develop treatment and rehabilitation plans reflective of presenting issues within 30 days of admission and after the first individual therapy session. Training will be provided in person by the Clinical Director in Clinical Rounds. Treatment plans will be discussed with clinical staff during weekly clinical supervisions, and treatment plan review periods, to ensure compliance. Compliance Manager along with Clinical Director will ensure the corrective action is implemented with monthly chart audits. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the client's individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client # 3 was admitted on August 15, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 19, 2025; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on April 14, 2025 and was discharged on July 7, 2025. The individual treatment and rehabilitation plan was completed on April 30, 2025 however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on January 9, 2025 and was discharged on April 19, 2025. The individual treatment and rehabilitation plan was completed on January 22, 2025; however, the plan did not include the type and frequency of treatment and rehabilitation services.
This is a repeat citation from the October 15, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be given to clinical staff during onboarding upon hire and ongoing within the clinic to identify and appropriately document type and frequency of treatment and rehabilitation services on the treatment plan. Training will be provided by the Clinical Director. Treatment plan documentation will be discussed with clinical staff during weekly clinical supervisions, and treatment plan review periods, to ensure compliance. Clinical supervision will be provided by the Clinical Director. Compliance Manager along with Clinical Director will also ensure the corrective action is implemented through monthly chart audits. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the client's individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client # 3 was admitted on August 15, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 19, 2025; however, the plan did not include documentation of any proposed type of support services.
Client # 4 was admitted on February 21, 2025 and was discharged on May 1, 2025. The individual treatment and rehabilitation plan was completed on March 6, 2025; however, the plan did not include documentation of any proposed type of support services.
Client # 6 was admitted on January 22, 2025 and was discharged on August 26, 2025. The individual treatment and rehabilitation plan was completed on February 19, 2025; however, the plan did not include documentation of any proposed type of support services.
This is a repeat citation from the October 15, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be provided to clinical staff during onboarding upon hire and ongoing within the clinic to identify/explore and appropriately document supportive services upon admission and in treatment plans that are conducive to recovery. Clinical Director will provide training as well as review charts in weekly supervision to ensure implementation. Compliance manager and Clinical Director will ensure corrective action is implemented with monthly chart audits. |