INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 6-7, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered.
Client #1 was admitted on February 26, 2026, and was still active at the time of the inspection. This client was prescribed Gabapentin, 800mg, to be taken three times a day. There were no notes in the medication administration record to document that the client had received her prescribed doses on March 2, 2026,
Client #3 was admitted on January 30, 2026, and was still active at the time of the inspection. This client was prescribed Buprenorphine, to be taken twice a day, one dose in the morning and one dose in the evening. There were no notes in the medication administration record to document that the client had received her prescribed evening dose on March 15, 2026, and March 23, 2026.
These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
It is Libertae's policy to assist clients in administering their medications according to the regimen outlined by the prescriber. Whenever a client declines to take a medication that has been prescribed, this will be documented in the client's record at the time of the medication (pass) administration. Clinical staff shall follow up with the client in order to determine if a medication monitoring appointment needs to be made with the prescriber in order to address any issues of non-adherence to the medication regimen. Facility staff who are responsible for overseeing medication administration have been updated on this procedure. The supervisor of this staff will conduct random chart reviews on a monthly basis to ensure that the plan of correction has been completed and sustained. Any instance of staff neglecting to document these instances will be addressed through follow-up training. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 complete treatment plans within time frames noted in the facility ' s policies. The facility ' s policy is to complete an initial treatment plan within seventy-two hours of admission to the facility.
Client #1 was admitted on February 26, 2026, and was still active at the time of the inspection. An initial treatment plan was due no later than March 1, 2026; however, the initial treatment plan was not completed until March 12, 2026.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Within 72 hours of admission, all clients meet with their individual counselor who will assist them in establishing a clinical treatment plan that includes the client's strengths, challenges, and goals, which are established in collaboration with the client and documented by the therapist.
To address the timeliness of initial treatment plans being submitted, Clinical Director will meet with the clinical team to review the requirement that treatment plans be entered within 72 hours of the client's admission to Libertae. To ensure ongoing compliance with this directive, Clinical Director will complete routine record audits, including reviewing treatment plans to ensure that there is documentation that the therapist completed the treatment plan within 72 hours of admission.
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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 client records, the facility failed to document treatment plan updates within the regulatory timeframe.
Client #2 was admitted on January 30, 2026, and was still active at the time of the inspection. A treatment plan update was completed on January 30, 2026, and the next update was due no later than March 2, 2026; however, the next documented treatment plan was completed March 16, 2026.
Client #3 was admitted on January 30, 2026, and was still active at the time of the inspection. A treatment plan update was completed on February 27, 2026, and the next update was due no later than March 29, 2026; however, the next documented treatment plan was completed April 7, 2026.
These findings were reviewed with facility staff during the complaint investigation.
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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 addressed by the Clinical Director, who will review the need for timely updating of clinical treatment plans with the clinical team. The Clinical Director will then complete regular record reviews to ensure ongoing adherence to this policy. The Clinical Director will address any clinical staff found to be entering treatment plan updates outside of the 30-day window.
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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 outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan.
Client #1 was admitted on February 26, 2026, and was still active at the time of the inspection. The comprehensive treatment plan, dated January 30, 2026, indicated one individual session per week. A review of the client record did not include documentation of a weekly individual session during the week of March 22-28, 2026.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Within the individualized treatment plan, it is determined by the counselor and client the number of individual and group sessions the client will receive per week. The counselor will then document that these services are being provided, which must align with what has been determined in the treatment plan.
To address this deficit, Clinical Director will meet with the clinical staff to provide education on the need to ensure that the individual and group counseling services provided align with the number of individual and group counseling services that have been determined as necessary in the client's treatment plan. The Clinical Director will additionally conduct ongoing chart audits to determine that each client is receiving the identified number of sessions in one calendar week (Monday-Sunday).
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