INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 7, 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's October 2024 through September 2025 fire drill logs, the facility failed to ensure their written fire drill logs included the time of the drill.The July 2025, August 2025 and September 2025 fire drill logs did not include documentation of the time of the drill.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic director will ensure that after coordinating monthly drills, the time of the drill will be documented as required.
In order to ensure accurate documentation, the office manager and clinic director will discuss during clinical rounds and do monthly checks to ensure logs are accurate |
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 the name of the person, agency, or organization to whom the disclosure is made to on consent to release information forms in one of seven client records reviewed. Client # 1 was admitted on August 20, 2025 and was still active at the time of the inspection. There was a release of information form signed by the client on September 17, 2025; however, the release form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ROI on file for noted client will be corrected immediately on 11/4/25, by having the clinician reach out to the client and appropriately fill this information in. Clinical staff will be trained during team meetings by clinic director to ensure that adequate and accurate information is found in regard to ROI's. Clinical director will review admission information and the office manager will also be trained and will review intake documentation to ensure that ROI's are filled in appropriately at time of admission. |
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 individual treatment and rehabilitation plan in three of seven applicable client records reviewed.Client # 1 was admitted on August 20, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 26, 2025, but the type and frequency of treatment and rehabilitation services was not documented on the treatment plan.Client # 2 was admitted on February 10, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 11, 2025, but the type and frequency of treatment and rehabilitation services was not documented on the treatment plan.Client # 6 was admitted on May 30, 2025 and was discharged on July 24, 2025. The individual treatment and rehabilitation plan was completed on March 11, 2025, but the type and frequency of treatment and rehabilitation services was not documented on the treatment plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff will be trained during staff meetings by the clinic director to ensure that frequency and type of service is documented in client's treatment plans moving forward and corrected on existing plans effective 11/4/25. Clinic director will audit charts weekly during supervision to ensure compliance with noted deficiency |
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 ensure treatment and rehabilitation plans are reviewed and updated at least every sixty days in two of three applicable client records reviewed. Client # 2 was admitted on February 10, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 11, 2025 and the first update was due no later than May 11, 2025; however, the update was not completed until May 21, 2025. Client # 3 was admitted on April 25, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 15, 2025 and the first update was due no later than July 15, 2025; however, the update was not completed until August 21, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic director will provide training to clinical staff and provide oversight to ensure that treatment plans are being developed, signed and reviewed at the appropriate time frames. During weekly supervision with clinical staff, auditing of treatment plans will take place to ensure compliance with noted deficiency |