INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Bold Steps of PA 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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705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on January 24, 2023, the facility failed to ensure frozen food was at or below 0*F. The facility did not have a mechanism to ensure the temperature of frozen food was at or below 0*F.This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Facility shall ensure freezer is at or below 0*F. Facility will place a self monitoring digital thermometer in the freezer. Ongoing: Monthly print outs from the self monitoring digital thermometer will be kept for review. Complete by 07/20/2026 |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of seven client records reviewed. Client #8 was admitted on June 9, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 12, 2026 with no type or frequency identified.Client #9 was admitted on May 18, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on May 26, 2026 with no type or frequency identified.Client #10 was admitted on June 18, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 18, 2026 with no type or frequency identified.Client #11 was admitted on June 5, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 12, 2026 with no type or frequency identified.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure that individual treatment plans will include both type and frequency of treatment. All clinical staff were retrained on the compliance regulation pertaining to type and frequency on 7/13/2026, For the next 60 days, Clinical Director will verify every treatment plan created will include the type and frequency of services. Ongoing: This item will be added to the random monthly EMR checks. Complete 7/14/26 |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in six out of seven client records reviewed. Client #1 was admitted on April 23, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on May 5, 2026 with no type or frequency identified.Client #2 was admitted on November 7, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 7, 2025 with no type or frequency identified.Client #4 was admitted on April 27, 2026 and was discharged on July 6, 2026. A comprehensive treatment plan was developed on April 28, 2026 with no type or frequency identified.Client #5 was admitted on September 8, 2025 and was discharged on January 12, 2026. A comprehensive treatment plan was developed on September 11, 2025 with no type or frequency identified.Client #6 was admitted on February 19, 2026 and was discharged on June 18, 2026. A comprehensive treatment plan was developed on February 19, 2026 with no type or frequency identified.Client #7 was admitted on December 16, 2025 and discharged on March 12, 2026. A comprehensive treatment plan was developed on December 22, 2025 with no type or frequency identified.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure that individual treatment plans will include both type and frequency of treatment. All clinical staff were retrained on the compliance regulation pertaining to type and frequency on 7/13/2026, For the next 60 days, Clinical Director will verify every treatment plan created will include the type and frequency of services. Ongoing: This item will be added to the random monthly EMR checks. Complete 7/14/26 |