INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 30, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Freedom Healthcare Services, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, administrative documentation and staff interviews, the facility failed to provide counseling to each client receiving drug and alcohol services on a regular and scheduled basis.
Approximately one hundred and thirty clients were recently transferred from a medication-only treatment program and admitted to the facility but were not receiving clinical services. There was no counseling sessions documented for these clients since being admitted.
These findings were reviewed with facility staff during the onsite complaint investigation
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Plan of Correction
709.92(d) ? Counseling Services
Correction:
Medication-only clients are no longer admitted to outpatient treatment. Clients transferred from a closing medication-only program are being transitioned to the facility's Office-Based Opioid Treatment (OBOT) program once operational. OBOT clients are encouraged to participate in counseling and provided referrals, consistent with OBOT requirements. All clients remaining in outpatient treatment receive regular, scheduled counseling. Admission procedures were revised to ensure appropriate level-of-care placement at admission.
Responsible: Facility Director
Compliance Date: April 15, 2026
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709.93(a) 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:
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Observations
Based on a review of client records, administrative documentation and staff interviews, the facility failed to maintain a complete client record for each client receiving drug and alcohol services.
Approximately one hundred and thirty clients were recently transferred from a medication-only treatment program and admitted to the facility. Those clients were not receiving clinical services as their records do not include documentation of treatment plans, case consultations, biopsychosocial assessments, progress notes, and consent to treatment.
These findings were reviewed with facility staff during the onsite complaint investigation
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Plan of Correction
709.93(a) ? Client Records
Correction:
A chart audit was conducted to identify appropriate level of care for transferred clients. All outpatient treatment clients maintain complete client records in accordance with DDAP regulations, including biopsychosocial assessments, treatment plans, progress notes, case consultations, and consent to treatment. Clients transitioned to OBOT maintain documentation appropriate to medication services, including informed consent, medical documentation, level-of-care designation, and referrals for counseling services. Clinical staff were retrained on documentation requirements by level of care. The Facility Director conducts ongoing supervisory chart reviews to ensure continued compliance.
Responsible: Facility Director
Compliance Date: April 15, 2026
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