This report is a result of an on-site licensure renewal inspection conducted on August 28, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Freedom Recovery Center, 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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Observations
Based on a review of client records, the facility failed to document case consultations, per their policy, in three of seven applicable records.
The facility's policy and procedures state a case consultation must be completed every 30 days.
Client #2 was admitted on November 19, 2024, and discharged on April 14, 2025. There was a case consultation documented on December 11, 2024, and the next one was due no later than January 11, 2025; however, there were no further case consultations documented in client #2 ' s record.
Client #3 was admitted on December 2, 2024, and discharged on February 27, 2025. There was a case consultation documented on January 5, 2025, and the next one was due no later than February 5, 2025; however, there were no further case consultations documented in client #3 ' s record.
Client #4 was admitted on February 4, 2025, and discharged on May 1, 2025. There was a case consultation documented on March 6, 2025, and the next one was due no later than April 6, 2025; however, there were no further case consultations documented in client #4 ' s record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 9-4-25 We have updated our case consultation policy and trained all staff on the new procedure. The Clinical Supervisor will ensure compliance by conducting random monthly charts audits. |