INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of applicable personnel records, the facility failed to ensure the project and facility director met the qualifications of the position at the time of hire in one of one records reviewed.
Staff #2 was hired as Operations Manager on March 23, 2025 and transitioned to Facility Director on May 13, 2026. Staff #2 did not meet the experience requirements to be the Facility Director.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Freedom Healthcare Services (FHS) reviewed the qualifications and reassessed the Facility Director position requirements.
2. FHS identifies that a qualified individual meeting all regulatory requirements is to hold that position. 3. FHS is actively seeking and interviewing candidates that meet the qualifications and experience to fill the position.
4. The Senior Leadership team has reviewed the hiring and promotion review process to include a documented qualification verification checklist prior to appointment to the Facility Director position.
5. All current Senior Leadership personnel have reviewed the regulation requirements to ensure compliance with qualification requirements of the position.
6. Ongoing, the Project Director will facilitate and/or participate in any interview(s) associated to the Facility Director position to ensure qualifications are met. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of administrative records, the facility failed to provide documentation of six months supervision upon employment of a clinical supervisor in one of one record.
Staff #3 was hired as a counselor on October 7, 2019 and promoted to a clinical supervisor on April 7, 2025. There is no documentation of monthly meetings for July, August, and September 2025 between staff #3 and the supervisor.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. The Clinical Supervisor's supervision file was reviewed and missing documentation addressed where possible.
2. A standardized Clinical Supervisor Supervision Log has been implemented to document all required monthly meetings.
Supervisor(s) have been retrained on documentation requirements for clinical supervision.
3. The Facility Director will review supervision logs monthly to ensure required meetings occur and are documented.
4. Quarterly audits will be completed to verify ongoing compliance.
5. Supervision has started as of 6/23/2026.
6. Meeting will occur monthly with an estimated completion date of 12/31/2026. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative documentation, the facility failed to complete an assessment of staff needs for current training year of January 2026-December 2026. The facility ' s policy states that this will be completed by January 31 of the training year.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 26, 2025 annual licensing inspection.
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Plan of Correction
1. Advise staff on when the training needs assessment form is to be completed and reason(s) why the completion of the form is necessary.
2. Staff training/discussion to occur on 6/16/2026.
3. A comprehensive staff training needs assessment for the 2026 training year has been completed for all employees.
4. A formal annual schedule has been established requiring completion of the assessment by employee and supervisor by December 31 each year.
5. The Project Director has been designated responsible for monitoring compliance.
6. Documentation of completion will be reviewed annually by Senior Leadership.
Quarterly compliance review will be conducted for within the Senior Leadership meetings for the calendar year of 2026 due to repeat citation status. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative documentation, the facility failed to complete an overall training plan for addressing staff training needs for the January 2026-December 2026 training year. The facility ' s policy states that this will be completed by January 31 of the training year.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 26, 2025 annual licensing inspection.
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Plan of Correction
1. All employee Training Need Assessment Forms for forthcoming year will be submitted to the Facility Director by January 7th.
2. Project Director and/or Facility Director will review forms to identify staff training needs.
3. Project Director and/or Facility Director and/or Clinical Supervisor will outline employee focus areas to assist employee on selecting CEUs for the upcoming year.
4. Annual calendar reminder has been established to ensure completion by January 31.
5. Senior Leadership will annually verify completion and implementation.
6. For the year 2026, all staff training needs assessments have been reviewed and outlined for the remainder of 2026. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documentation, the facility failed to complete an annual evaluation of their overall training plan for the January 2025-December 2025 training year. The facility ' s policy states that this will be completed by January 31 of the training year.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 26, 2025 annual licensing inspection.
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Plan of Correction
1. Project Director and/or Facility Director and/or Clinical Supervisor will communicate with employee and provide written documentation of area(s) of focus by January 31.
2. During Clinical Supervision Meetings, at least once monthly, a review of progress toward training objectives will be discussed with clinical staff.
Results of evaluations will be used to guide future training needs assessments and annual training plans.
3. Annual calendar reminders have been established to ensure completion by January 31st.
4. Senior Leadership will annually verify completion and implementation.
The Clinical Supervisor will maintain documentation of evaluations and report findings to Senior Leadership annually.
5. For the year 2026, all staff training needs assessments have been reviewed and outlined for the remainder of 2026.
6. A specialized meeting has been established to occur annually in January with Senior Leadership and the clinical team. Planned date of this meeting will be 1/12/2027. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure the FTE counselor caseload in the outpatient activity did not exceed 35 active clients in four of five applicable staff reviewed. Additionally, the facility's overall caseload for the outpatient program exceeded 35 active clients.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 35. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The facility ' s caseload calculation is as follows: 118.5/35=3.38 (FTE); 202/3.38 = 59.76, which equals to a client/counselor ratio of 59:1.
The Full Time Equivalent (FTE) is determined by dividing the total number of hours counselors devote to their clients by the facility ' s standard workweek of 35 hours. Then, in order to obtain the facility ' s ratio, the total number of clients on the counselors ' caseload is divided by the FTE.
Staff #3 was hired as a counselor on October 7, 2019 and promoted to a clinical supervisor on April 7, 2025. Staff #3 was reported to have 15 hours per week devoted to their 40 clients on their caseload. The FTE counselor ' s caseload calculation is as follows: 15/35 = .42(FTE); 40/.42 = 95.23, which equals to a client/counselor ratio of 95:1.
Staff #4 was hired as a counselor on February 16, 2026 and was still in this position at the time of the inspection. Staff #4 was reported to have 30.5 hours per week devoted to their 59 clients on their caseload. The FTE counselor ' s caseload calculation is as follows: 30.5/35 = .87(FTE); 59/.87 = 67.81, which equals to a client/counselor ratio of 67:1.
Staff #6 was hired as a counselor on March 5, 2013 and was still in this position at the time of the inspection. Staff #6 was reported to have 35 hours per week devoted to their 43 clients on their caseload. The FTE counselor ' s caseload calculation is as follows: 35/35 = 1(FTE); 43/1 = 43, which equals to a client/counselor ratio of 43:1.
Staff #7 was hired as a counselor on November 1, 2016 and was still in this position at the time of the inspection. Staff #7 was reported to have 32 hours per week devoted to their 56 clients on their caseload. The FTE counselor ' s caseload calculation is as follows: 32/35 = .91(FTE); 56/.91 = 61.53, which equals to a client/counselor ratio of 61:1.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Caseloads were immediately reviewed and redistributed among clinical staff as applicable.
2. The facility completed an analysis of staffing needs and initiated recruitment efforts to increase counseling capacity.
3. Admissions may be temporarily limited when necessary to maintain compliance with counselor-to-client ratios.
4. A monthly caseload monitoring report has been implemented and will be reviewed by the Clinical Supervisor and/or Facility Director and Clinical Supervisor.
5. Any counselor approaching regulatory limits will have caseload adjustments made immediately. |
709.92(a) 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:
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client based on the facility ' s policy in six of seven records. The facility ' s policy states that the initial comprehensive treatment and rehabilitation plan will be developed with the client within thirty days of admission.
Client #1 was admitted on September 16, 2025 and was still active at the time of the inspection.
The initial comprehensive treatment and rehabilitation plan developed on October 14, 2025 did not include documentation of the plan being developed with the client.
Client #2 was admitted on January 14, 2026 and was still active at the time of the inspection.
The initial comprehensive treatment and rehabilitation plan was due to be completed no later than February 14, 2026; however, this was not completed until March 3, 2026. Additionally, the comprehensive treatment and rehabilitation plan did not include documentation of the plan being developed with the client.
Client #4 was admitted on September 18, 2025 and was still active at the time of the inspection.
The initial comprehensive treatment and rehabilitation plan was due to be completed no later than October 18, 2025; however, this was not completed until November 5, 2025.
Client #5 was admitted on November 6, 2025 and was discharged on May 21, 2026.
The initial comprehensive treatment and rehabilitation plan was due to be completed no later than December 6, 2025; however, this was not completed until February 11, 2026. Additionally, the comprehensive treatment and rehabilitation plan did not include documentation of the plan being developed with the client.
Client #6 was admitted on September 23, 2025 and was discharged on April 29, 2026.
The initial comprehensive treatment and rehabilitation plan was due to be completed no later than October 23, 2025; however, this was not completed until November 3, 2025. Additionally, the comprehensive treatment and rehabilitation plan did not include documentation of the plan being developed with the client.
Client #7 was admitted on December 22, 2025 and was discharged on February 10, 2026.
The initial comprehensive treatment and rehabilitation plan was due to be completed no later than January 22, 2026; however, this was not completed until January 27, 2026. Additionally, the comprehensive treatment and rehabilitation plan did not include documentation of the plan being developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. All active client records were audited to ensure treatment plans are completed timely and contain documentation of client participation.
2. Treatment plan training was conducted to include a required client participation acknowledgment.
3. Incomplete Document Report is to be ran weekly on or around Thursday to generate alerts for upcoming treatment plan due dates.
4. The Clinical Supervisor will conduct monthly chart audits to monitor compliance and provide corrective coaching as needed. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of six applicable records.
Client #3 was admitted on October 28, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on March 17, 2026. The next treatment and rehabilitation plan update was due no later than May 17, 2026; however, this was not completed at the time of the inspection.
Client #4 was admitted on September 18, 2025 and was still active at the time of the inspection.
A treatment and rehabilitation plan update was completed on February 11, 2026. The next treatment and rehabilitation plan update was due no later than April 13, 2026; however, this was not completed until June 2, 2026.
Client #6 was admitted on September 23, 2025 and was discharged on April 29, 2026.
A treatment and rehabilitation plan update was completed on February 25, 2026. The next treatment and rehabilitation plan update was due no later than April 27, 2026; however, this was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 26, 2025 annual licensing inspection.
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Plan of Correction
1. All active client charts were reviewed and overdue treatment plan updates completed.
2. Clinical staff received retraining on meeting deadlines for treatment plans.
3. Clinical staff received training regarding regulatory review requirements.
4. Incomplete Document Report is to be ran weekly on or around Thursday to generate alerts for upcoming treatment plan due dates.
5. The Clinical Supervisor will conduct monthly chart audits to monitor compliance and provide corrective coaching as needed.
6. Revision to the Treatment Plan Policy has been completed to modify when Treatment Plans are due. |
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 applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in four of six records. The facility policy and procedure manual indicate a case consultation to within three months, six months, nine months, and twelve months of admission. A case consultation will occur annually thereafter.
Client #2 was admitted on January 14, 2026 and was still active at the time of the inspection.
The three-month case consultation was due to occur no later than April 14, 2026; however, this was not completed at the time of the inspection.
Client #3 was admitted on October 28, 2025 and was still active at the time of the inspection. The six-month case consultation was due to occur no later than April 28, 2026; however, this was not completed at the time of the inspection.
Client #5 was admitted on November 6, 2025 and was discharged on May 21, 2026.
The three-month case consultation was due to occur no later than February 6, 2026; however, this was not completed at the time of the inspection. Additionally, the six-month case consultation was due to occur no later than May 6, 2026; however, this was not completed at the time of the inspection.
Client #6 was admitted on September 23, 2025 and was discharged on April 29, 2026.
The three-month case consultation was due to occur no later than December 23, 2025; however, this was not completed at the time of the inspection. Additionally, the six-month case consultation was due to occur no later than March 23, 2026; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Active client records were reviewed, and all overdue case consultations were completed where applicable.
2. Incomplete Document Report is to be ran weekly on or around Thursday to generate alerts for upcoming CASE CONSULT due dates.
3. Revision to the Case Consult Policy has been completed to modify when Case Consults are due.
4. Clinical staff were retrained on facility policy regarding case consultation requirements.
5. The Clinical Supervisor will review consultation due dates monthly and ensure timely completion.
6. The Clinical Supervisor will conduct quarterly chart audits verify compliance with consultation requirements and corrective action will be taken when deficiencies are identified. |