INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2024, through December 20, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, Inc. 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on December 20, 2024, the facility failed to ensure that the grounds of the facility were in good repair at all times. In the childcare yard, five window screens were bent and ill-fitting, resulting in sharp corners sticking out. Below one of the bent screens was an area with loose siding, which was jutting out from the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. New screens have been installed where needed.
The Maintenance Technician for Libertae shall ensure that the deficiency does not reoccur by way of regular monthly walk throughs of all buildings and grounds to identify areas for repair or replacements. All staff and clients are instructed to report any issues concerning buildings and grounds, particularly for safety, to report same to the Maintenance Technician. |
705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on a physical plant inspection on December 20, 2024, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks. The bathroom in bedroom 26 contained acetone nail polish remover that was not secured with safety latches or locks.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. All line staff (treatment techs) have been made aware of the necessity of securing hazardous and poisonous substances and materials in cabinets with safety latches or locks.
It is the responsibility of the Treatment Tech supervisor to onboard and train new staff in all safety protocols. Treatment Techs regularly inspect all living areas to detect any hazards and/or poisonous substances and ensure that they are immediately secured in locked cabinets. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of twelve client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 3 was admitted on August 28, 2024 and was involuntarily discharged on November 21, 2024. The record contained no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients who are involuntarily terminated from Libertae receive a letter, signed by the Clinical Director, indicating their administrative discharge status, as well as the date and time at which their status as a resident of Libertae will be terminated. These letters are provided to the client and a copy is uploaded to their treatment record, indicating whether or not the client has accepted their copy of the letter.
The Clinical Director will correct this deficiency by informing the clinical therapists of this requirement and implementing record reviews for the charts of all discharged clients, including those who have been involuntarily terminated from Libertae. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within fourteen days of admission, per facility policy, in three applicable records reviewed.
Client # 1 was admitted on February 22, 2024 and was transferred to a lower level of care on May 15, 2024. The record did not contain a psychosocial evaluation.
Client # 2 was admitted on April 25, 2024 and was transferred to a lower level of care on June 17, 2024. The psychosocial evaluation was not completed until May 14, 2024.
Client # 6 was admitted on August 14, 2024 and was active at the time of the inspection. The record contained a psychosocial evaluation; however, it was not dated to confirm it was completed according to the timeframe of the facility policy.
This is a repeat citation from the December 18, 2023 annual licensing renewal inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Biopsychosocial evaluations are completed collaboratively with the therapist and client within the first 14 days of admission to Libertae. Biopsychosocial evaluations will be signed and dated by the therapist to indicate compliance with the expected timeframe of completion.
The deficiency will be corrected by the Clinical Director, who will instruct the clinical therapists of this requirement and the specified timeline, including the requirement to sign and date biopsychosocial evaluations. The Clinical Director will also engage in frequent record reviews to ensure adherence to this policy. The Clinical Director will work with clinical staff around barriers to timely completion of biopsychosocial evaluations for clients. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three applicable records reviewed.
Client # 4 was admitted on March 5, 2024 and was discharged on May 22, 2024. A treatment plan update was completed on April 4, 2024, and the next treatment plan update was due no later than May 4, 2024; however, no treatment plan updates were completed prior to discharge.
Client # 5 was admitted on September 11, 2024 and was active at the time of the inspection. A treatment plan update was completed on October 11, 2024, and the next treatment plan update was due no later than November 10, 2024; however, the update was not completed until November 25, 2024.
Client # 6 was admitted on August 14, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 15, 2024, and the next treatment plan update was due no later than September 14, 2024; however, the update was not completed until September 27, 2024.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Upon admission, an individualized treatment plan is established collaboratively with the client. The treatment plan is updated every 30 days thereafter, reflecting changes and updates based on the client's progress.
This deficiency will be corrected by the Clinical Director, who will review this policy with clinical staff, particularly regarding the timely updating of clinical treatment plans. The Clinical Director will complete regular record reviews to ensure the ongoing adherence to this policy regarding treatment plan updates. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in five of seven records reviewed.
Client # 1 was admitted on February 22, 2024 and was transferred to a lower level of care on May 15, 2024. The treatment plan completed on February 22, 2024, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered between March 8, 2024 and March 18, 2024.
Client # 3 was admitted on August 28, 2024 and was discharged on November 21, 2024. The treatment plan completed on August 30, 2024, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered between September 4, 2024 and September 16, 2024.
Client # 4 was admitted on March 5, 2024 and was discharged on May 22, 2024. The treatment plan completed on April 4, 2024, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered between April 4, 2024 and April 18, 2024, or between April 25, 2024 and May 17, 2024.
Client # 6 was admitted on August 14, 2024 and was active at the time of the inspection. The treatment plan completed on August 15, 2024, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered between September 5, 2024 and September 16, 2024.
Client # 7 was admitted on October 31, 2024 and was active at the time of the inspection. The treatment plan completed on November 26, 2024, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered between November 27, 2024 and December 12, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical therapist is responsible for the provision of at least one individual counseling session of one hour per week for 3.1 level of care , or two one hour sessions per week for 3.5 level of care clients, or more, depending on the needs of the client and what is established in the creation of their clinical treatment plan. When a therapist is unable to meet with a client due to client's illness or scheduling conflict related to work, outside appointments, etc., the therapist will make every attempt to reschedule the session within the week. If this is not possible, the therapist will document the attempts and communication involved. In the case of a therapist's planned absence, a client may be temporarily reassigned to another team member, as needed.
The Clinical Director will review this policy with all counseling staff. Clinical Director will complete regular record reviews to ensure that all clients are being provided counseling sessions at the identified frequency. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in two of five applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed every 90 days.
Client # 5 was admitted on September 11, 2024 and was active at the time of the inspection. The record did not contain documentation of a case consultation note.
Client # 6 was admitted on August 14, 2024 and was active at the time of the inspection. The record did not contain documentation of a case consultation note.
This is a repeat citation from the December 18, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients' progress in treatment is regularly reviewed by the multidisciplinary team, which meets at least weekly. The client's therapist of record will document the case consultation in the client's record at a minimum of eery 90 days, and more frequently if needed.
The Clinical Director will correct the deficiency by instructing the clinical therapists in this required practice, and ensuring, through regular record reviews, that the client treatment records are complete, including documented case consultation notes. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in one of two applicable records reviewed.
Client # 3 was admitted on August 28, 2024 and was discharged on November 21, 2024. The record did not contain documentation of follow-up information.
This is a repeat citation from the December 18, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Seven days post discharge, the therapist of record will attempt to contact the client via phone to determine her post-treatment disposition. Once the attempt at contact has ben made and documented, the client chart will be considered complete and service to the individual fulfilled.
This deficiency will be addressed by the Clinical Director, who will instruct the clinical therapists of the expectation of contact and documented follow-up within 7 days, for each client who is discharged from Libertae. The Clinical Director will ensure that the deficiency does not reoccur by performing regular record reviews of completed charts to ensure that all include documentation of contact following discharge. |
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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in six of six applicable records reviewed.
Client # 8 was transferred from a higher level of care on June 17, 2024 and was discharged on December 2, 2024. A treatment plan update was completed on May 25, 2024 in a higher level of care; however, no treatment plan updates were completed prior to the client ' s discharge from the outpatient level of care.
Client # 9 was transferred from a higher level of care on February 2, 2024 and was discharged on August 13, 2024. A treatment plan update was completed on January 26, 2024 in a higher level of care; however, no treatment plan updates were completed prior to the client ' s discharge from the outpatient level of care.
Client # 10 was transferred from a higher level of care on January 16, 2024 and was discharged on May 12, 2024. A treatment plan update was completed on December 22, 2023 in a higher level of care; however, no treatment plan updates were completed prior to the client ' s discharge from the outpatient level of care.
Client # 12 was transferred from a higher level of care on March 15, 2024 and was active at the time of the inspection. A treatment plan update was completed on February 29, 2024 in a higher level of care; however, no treatment plan updates were completed in the outpatient level of care prior to the date of the inspection.
Client # 13 was transferred from a higher level of care on August 20, 2024 and was active at the time of the inspection. A treatment plan update was completed on July 12, 2024 in a higher level of care; however, no treatment plan updates were completed in the outpatient level of care prior to the date of the inspection.
Client # 14 was transferred from a higher level of care on May 15, 2024 and was active at the time of the inspection. A treatment plan update was completed on April 22, 2024 in a higher level of care; however, no treatment plan updates were completed in the outpatient level of care prior to the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Upon admission to the outpatient program, an individualized treatment plan is established collaboratively with the client. The treatment plan is updated every 60 days thereafter, reflecting changes and updates based on the client's progress.
The deficiency will be addressed by the Clinical Director, who will review this policy and expectation with outpatient clinical staff. The clinical Director will ensure the deficiency does not reoccur by completing regular record reviews to ensure ongoing adherence to the policy. |
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 and the facility ' s policy and procedure manual, the facility failed to ensure that counseling was provided to a client on a regular and scheduled basis in three of five applicable records reviewed. Facility staff stated that clients in the outpatient level of care are to be offered one individual session and one group session per month.
Client # 8 was transferred from a higher level of care on June 17, 2024 and was discharged on December 2, 2024. The record did not contain documentation that any individual sessions were documented for the month of August 2024.
Client # 9 was transferred from a higher level of care on February 2, 2024 and was discharged on August 13, 2024. The record did not contain documentation that any individual sessions were documented for the month of June 2024.
Client # 13 was transferred from a higher level of care on August 20, 2024 and was active at the time of the inspection. The record did not contain documentation that any group sessions were documented for the months of October or November 2024.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The outpatient clinical therapist is responsible for the provision of at least one individual counseling session per month (at the OP Level of Care), or more depending on the needs of the client and what has been established in the formulation of the client's clinical treatment plan. When a therapist is unable to met with a client for any reason, such as client's illness, conflict with work schedule, or other necessary appointments, the therapist will make every attempt to reschedule the session within that month. If this is not possible, the therapist will document the attempts and communication involved.
The Clinical Director shall review this policy with the outpatient clinical staff. The Clinical Director shall complete regular record reviews to ensure that the deficiency does not reoccur, and that all clients are being provided counseling sessions at the identified frequency, or documents why this may not be the case. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed before the end of the week, in four of seven records reviewed.
Client # 8 was transferred from a higher level of care on June 17, 2024 and was discharged on December 2, 2024. The record contained a progress note for an individual session occurring on November 26, 2024, that was not completed until December 17, 2024.
Client # 10 was transferred from a higher level of care on January 16, 2024 and was discharged on May 12, 2024. The record contained a progress note for an individual session occurring on April 18, 2024, that was not completed until April 26, 2024.
Client # 13 was transferred from a higher level of care on August 20, 2024 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on September 24, 2024, that was not completed until October 3, 2024.
Client # 14 was transferred from a higher level of care on May 15, 2024 and was active at the time of the inspection. The record contained progress notes for a group session occurring on October 1, 2024, that was not completed until October 15, 2024, as well as group sessions occurring on October 29, 2024 and November 19, 2024, that were not completed until December 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff are expected to enter progress notes within the calendar week (Monday-Friday)in which an individual or group session occurs. This allows for the most accurate transmission of information regarding what occurred in the session and for the creation of a complete record that indicates the client's treatment engagement in the most precise manner possible.
The deficiency shall be addressed by the Clinical Director, who will review the policy of entering progress notes within the calendar week with clinical staff. The Clinical Director shall monitor the clinical team's performance in this area by way of regular chart reviews. |
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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in seven of seven applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed every 90 days.
Client # 8 was transferred from a higher level of care on June 17, 2024 and was discharged on December 2, 2024. The record did not contain documentation of case consultation notes.
Client # 9 was transferred from a higher level of care on February 2, 2024 and was discharged on August 13, 2024. The record did not contain documentation of case consultation notes.
Client # 10 was transferred from a higher level of care on January 16, 2024 and was discharged on May 12, 2024. The record did not contain documentation of case consultation notes.
Client # 11 was transferred from a higher level of care on December 19, 2023 and was discharged on August 14, 2024. The record did not contain documentation of case consultation notes.
Client # 12 was transferred from a higher level of care on March 15, 2024 and was active at the time of the inspection. The record did not contain documentation of case consultation notes.
Client # 13 was transferred from a higher level of care on August 20, 2024 and was active at the time of the inspection. The record did not contain documentation of case consultation notes.
Client # 14 was transferred from a higher level of care on May 15, 2024 and was active at the time of the inspection. The record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients' progress in treatment is regularly reviewed by the multidisciplinary team which meets at least weekly. The client's assigned therapist will document the case consultation held at the team meeting at a minimum of every 90 days, and more frequently if needed.
The Clinical Director shall address this deficiency by instructing the clinical outpatient therapists of this requirement, and shall ensure adherence to this regulation by conducting regular record reviews, to note that client treatment records are complete and include case consultation notes. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary within seven days of discharge, in four of four applicable records reviewed.
Client # 8 was transferred from a higher level of care on June 17, 2024 and was discharged on December 2, 2024. The record did not contain a discharge summary.
Client # 9 was transferred from a higher level of care on February 2, 2024 and was discharged on August 13, 2024. The record did not contain a discharge summary.
Client # 10 was transferred from a higher level of care on January 16, 2024 and was discharged on May 12, 2024. The record did not contain a discharge summary.
Client # 11 was transferred from a higher level of care on December 19, 2023 and was discharged on August 14, 2024. The record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A discharge summary that includes the client's disposition and status at completion of treatment, demographics, progress in treatment, prognosis, and aftercare treatment recommendations will be included in each client's record as part of a complete chart. The discharge summary will be written, signed by the therapist of record and entered into the client's chart within 7 days post-discharge from the program.
This deficiency will be corrected by the Clinical Director, who will instruct clinical therapists of the policy of completing signed discharge summaries within the required timeframe. The correction shall be monitored by the Clinical Director, who shall conduct chart audits on a regular basis to determine that discharge summaries have been charted for each client within the 7 day timeframe. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within seven days of discharge, per facility policy, in three of five applicable records reviewed.
Client # 8 was transferred from a higher level of care on June 17, 2024 and was discharged on December 2, 2024. The record did not contain documentation of follow-up information.
Client # 11 was transferred from a higher level of care on December 19, 2023 and was discharged on August 14, 2024. The record did not contain documentation of follow-up information.
Client # 15 was transferred from a higher level of care on June 13, 2023 and was discharged on March 11, 2024. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The outpatient therapist will attempt to conduct a 7 day follow up via telephone with any client who has been discharged from the outpatient program. This attempt will be documented in the client's chart. Once this documentation is made, the client chart will be considered complete.
This deficiency will be addressed by the Clinical Director, who will instruct the clinical therapist of the expectation of contact and documentation of same within the 7 day timeframe for all discharged clients. Adherence to the policy will be monitored by the Clinical Director, who will perform regular chart audits to ensure that all closed charts are complete and accurate, including documentation of follow-up contact attempt. |