INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2, 2025 through December 3, 2025 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility's July 2024 through June 2025 training year in one of five applicable personnel records reviewed. Employee #3 was hired as a counselor on May 31, 2022. There was only 23 annual training hours documented in the personnel record for the training year reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Libertae offers scheduled training opportunities throughout the year, including several trainings which are mandatory for all staff, including counselors. Counselors also create a yearly training plan with their supervisor which includes their specific areas of interest in seeking out more tailored trainings for themselves for the year.
To ensure all counselors meet or exceed the annual training requirement going forward, the Clinical Director will work with Libertae's Office Manager to closely monitor counselor training records and identify any gaps early in the training cycle. Training progress will be addressed in individual supervision between the Clinical Director and counselor, and training engagement will be addressed in yearly performance appraisal. Counselors will be provided with a variety of training opportunities related to their identified areas of professional growth and development.
The Clinical Director shall meet with the Office Manager to review the monitoring tool employed to track counselor training records by January 15, 2026. The Clinical Director and Office Manager will subsequently check in on a quarterly basis to ensure that the corrective action has resulted in total compliance on the part of counseling staff meeting required training hours.
The corrective action will be completed by January 15, 2026.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in three of fourteen client records reviewed.Client #9 was admitted to the outpatient activity on May 27, 2025 and was active at the time of the inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.Client #10 was admitted to the outpatient activity on June 3, 2025 and was active at the time of the inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.Client #11 was admitted to the outpatient activity on July 31, 2025 and was discharged on August 12, 2025. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon admission, all clients sign required consent forms for the release of confidential information, including a release to their funding source. To correct this deficit, the Clinical Director will review the consent form packet for outpatient clients with lead outpatient counselor, which includes a consent for release of information to the client's funding source. The Clinical Director will also conduct regular chart audits of outpatient client charts to ensure that new clients have signed a release for their funding source and that this release is uploaded to their chart. Chart audits will be conducted quarterly. Date of completion shall be 1/15/2026.
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709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on release of information forms in one of fourteen client records reviewed. Client #3 was admitted to the inpatient non-hospital activity August 14, 2025 and was active at the time of the inspection. There were release of information forms to a funding source, another treatment provider, two separate government agencies, an emergency contact, a pharmacy and an urinalysis laboratory signed by the client; however, the date of the client ' s signature was not documented on any of the release forms.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will receive education regarding properly completing releases of information, to include indicating the date of the client's signature. This will be reviewed with all staff who may be signing releases, including Manager of Admissions, Case Managers, and Counselors, by their supervisor. Adherence to this correction will be monitored by Clinical Director, who will conduct routine chart audits to ensure that all consent forms are completed correctly and fully, including dating the client's signature.
Date of completion of this plan of correction shall be 1/15/2026.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in two of fourteen client records reviewed.Client #5 was admitted to the inpatient non-hospital activity on May 6, 2025 and was discharged on July 10, 2025. There were release of information forms to two separate emergency contacts that were signed and dated by the client on May 6, 2025; however, there was no documentation in the record indicating a copy of either release form was offered to the client. Client #6 was admitted to the inpatient non-hospital activity on April 11, 2025 and was discharged on June 12, 2025. There were release of information forms to three separate government agencies and an attorney that were signed and dated by the client on May 1, 2025; however, there was no documentation in the record indicating a copy of any of the release forms were offered to the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will receive education regarding properly completing releases of information, to include indicating that a copy has been offered to the client and whether or not the client accepted the offered copy. This will be reviewed with all staff who may be signing releases, including Manager of Admissions, Case Managers, and Counselors, by their supervisor. Adherence to this correction will be monitored by Clinical Director, who will conduct routine chart audits to ensure that all consent forms are being completed correctly and fully, including indicating whether the copy offered to the client was accepted or declined.
Date of completion shall be 1/15/2026. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records and discussions with project staff, the project failed to maintain a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance.At the time of the inspection, the facility does not keep paper client records, and all paper documentation is to be scanned into the electronic record by the staff in a timely fashion. During the course of the client record review, there were two outpatient client records that were missing all the intake and admission documents and only had treatment plan updates and progress notes documented. A third, active outpatient client record, with an admission date of November 13, 2025, was briefly reviewed and there was no documentation at all in the record. Additionally, in several of the discharged client records reviewed, there was documentation that was uploaded to the electronic record several months after they were completed and the client was already discharged. After a discussion with the project director and the clinical supervisor, it was determined that staff were not uploading documents to the electronic record timely.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Libertae shall maintain a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance. The Director of Operations shall review the current technology that supports all documentation and make recommendations for upgrades that meet the licensure requirements vis a vis record keeping. This corrective action will be completed by 1/15/2026. The clinical director will monitor the record keeping system on a monthly basis to determine that staff have entered all documentation into the electronic record system in a timely fashion. The clinical director shall report to the project director any issues that impede the progress toward full compliance with this regulation. |
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 client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of two applicable client records reviewed.Client #11 was admitted to the outpatient activity on July 31, 2025 and was involuntarily terminated on August 12, 2025. There was no documentation, in the record, indicating the client received written notice of the involuntary termination from the project.This is a repeat citation from the December 20, 2024 annual licensing renewal inspection. This finding was 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.
Clinical Director will resolve this deficiency by advising 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.
this plan of correction shall be completed by 1/15/2026.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide the client with an opportunity to request reconsideration of a decision terminating treatment in one of two applicable client records reviewed.Client #11 was admitted to the outpatient activity on July 31, 2025 and was involuntarily terminated on August 12, 2025. There was no documentation, in the record, indicating the client was given the opportunity to request reconsideration of the involuntary termination from the project.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of Libertae to provide any client who is involuntarily terminated from treatment the opportunity to request reconsideration of this decision. Clients who are involuntarily terminated from Libertae receive a letter, signed by the Clinical Director, indicating their administrative discharge status, as well as the process by which they may re-apply for admission. 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. Should the client decide to request reconsideration, the formal process shall be implemented and followed.
Clinical Director will resolve this deficiency by advising 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.
This deficiency shall be corrected by 1/15/2026 and monitored quarterly for compliance. Any further deficiencies shall be discussed and addressed in quarterly Quality Assurance meetings.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document, during the intake and admission process, a physical examination of the client in three of seven client records reviewed.Client #1 was admitted to the inpatient non-hospital activity on June 6, 2025 and was active at the time of the inspection. There was no documentation, in the record, indicating a physical examination of the client was completed.Client #2 was admitted to the inpatient non-hospital activity on June 25, 2025 and was active at the time of the inspection. There was no documentation, in the record, indicating a physical examination of the client was completed.Client #5 was admitted to the inpatient non-hospital activity on May 6, 2025 and was discharged on July 10, 2025. There was no documentation, in the record, indicating a physical examination of the client was completed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon admission to Libertae, all clients meet with their case manager to establish if they have had a recent physical examination or if a new physical examination is required. To address this deficit, Libertae's medical director will perform physical examinations for each client admitted to the 3.5 level of care and will review the physical exam completed by the referring facility for clients transferring into the 3.1 LOC. Additionally, clients who admit to the 3.1 level of care without a recent physical exam will receive a physical examination upon admission as well. Director of Social Services will review physical examination requirements with case management team. Case managers will assist clients in scheduling necessary medical appointments. To ensure that this correction is maintained, Clinical Director will regularly audit charts of all clients for record of a completed physical examination in the chart.
This plan of correction shall be implemented and completed by 1/15/2026. |
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 ensure the individual treatment and rehabilitation plan was developed with the client in four of seven client records reviewed. Client #1 was admitted to the inpatient non-hospital activity on June 6, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 17, 2025; however, there was no documentation in the record indicating the plan was developed with the client. Client #2 was admitted to the inpatient non-hospital activity on June 25, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 25, 2025; however, there was no documentation in the record indicating the plan was developed with the client.Client #3 was admitted to the inpatient non-hospital activity on August 14, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 14, 2025; however, there was no documentation in the record indicating the plan was developed with the client.Client #6 was admitted to the inpatient non-hospital activity on April 11, 2025 and was discharged on June 12, 2025. The individual treatment and rehabilitation plan was completed on April 11, 2025; however, there was no documentation in the record indicating the plan was developed with the client.This finding was reviewed with facility staff during the licensing process.
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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, including strengths, challenges, and goals, which are established in collaboration with the client and documented by the therapist.
To address this deficit, Clinical Director will meet with the clinical team to review the need to document that the completion of the treatment plan was a collaborative effort between client and therapist and that this occurred in the first session. To ensure ongoing compliance with this directive, Clinical Director will complete routine record audits, including reviewing treatment plans and individual therapy session notes to ensure that there is documentation that the therapist completed the treatment plan with the client.
This plan of correction shall be implemented and completed by 1/15/2026.
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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 maintain a complete client record, which is to include the documentation of case consultation notes, in three of six applicable records reviewed. The facility policy manual indicates case consultations will be completed and documented every 90 days. Client #1 was admitted to the inpatient non-hospital activity on June 6, 2025 and was active at the time of the inspection. There was no case consultation notes documented in the record as of the date of the inspection. Client #2 was admitted to the inpatient non-hospital activity on June 25, 2025 and was active at the time of the inspection. The first case consultation was to occur no later than September 25, 2025; however, the consultation was completed and documented on November 19, 2025. Client #3 was admitted to the inpatient non-hospital activity on August 14, 2025 and was active at the time of the inspection. There was no case consultation notes documented in the record as of the date of the inspection.This is a repeat citation from the December 18, 2023 and December 20, 2024 annual licensing renewal inspections.This finding was 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. The client's assigned therapist will document the case consultation in the client's record at a minimum of every 90 days, and more frequently if needed.
Clinical Director will address this deficiency by advising the clinical team of this requirement and ensuring, through regular record reviews, that the client treatment records are complete, including the presence of case consultation notes.
This plan of correction shall be implemented and completed by 1/15/2026. It shall be monitored quarterly.
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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 a review of client records, the facility failed to ensure the individual treatment and rehabilitation plan was developed with the client in seven of seven applicable client records reviewed. Client #8 was admitted to the outpatient activity on May 6, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 23, 2025; however, there was no documentation in the record indicating the plan was developed with the client.Client #9 was admitted to the outpatient activity on May 27, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 24, 2025; however, there was no documentation in the record indicating the plan was developed with the client. Client #10 was admitted to the outpatient activity on June 3, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 23, 2025; however, there was no documentation in the record indicating the plan was developed with the client.Client #11 was admitted to the outpatient activity on July 31, 2025 and was discharged on August 12, 2025. The individual treatment and rehabilitation plan was completed on July 31, 2025; however, there was no documentation in the record indicating the plan was developed with the client.Client #12 was admitted to the outpatient activity on February 19, 2025 and was discharged on October 15, 2025. The individual treatment and rehabilitation plan was completed on March 7, 2025; however, there was no documentation in the record indicating the plan was developed with the client.Client #13 was admitted to the outpatient activity on June 12, 2025 and was discharged on July 17, 2025. The individual treatment and rehabilitation plan was completed on June 23, 2025; however, there was no documentation in the record indicating the plan was developed with the client.Client #14 was admitted to the outpatient activity on February 10, 2025 and was discharged on March 28, 2025. There was an individual treatment and rehabilitation plan dated February 5, 2025; however, the entire treatment plan was blank and not completed.This finding was reviewed with facility staff during the licensing process.
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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, including strengths, challenges, and goals, which are established in collaboration with the client and documented by the therapist.
To address this deficit, Clinical Director will meet with the outpatient clinical team to review the need to document that the completion of the treatment plan was a collaborative effort between client and therapist and that this occurred in the first session. To ensure ongoing compliance with this directive, Clinical Director will complete routine record audits, including reviewing treatment plans and individual therapy session notes to ensure that there is documentation that the therapist completed the treatment plan with the client.
this plan of correction shall be implemented and completed by 1/15/2026.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of an aftercare plan, in two of three applicable client records reviewed. Client #13 was admitted to the outpatient activity on June 12, 2025 and was discharged on July 17, 2025. There was no documentation in the record indicating an aftercare plan was completed at the time of the inspection. Client #14 was admitted to the outpatient activity on February 10, 2025 and was discharged on March 28, 2025. There was no documentation in the record indicating an aftercare plan was 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
When clients discharge from the outpatient program, an aftercare plan that indicates their recommended level of care is completed with them, as appropriate. Clinical Director will address this deficit by reviewing this requirement with outpatient therapists and completing routine record audits to ensure that aftercare plans are being completed and included in the chart.
This plan of correction shall be implemented and completed by 1/15/2026. The Clinical Director will monitor the plan on a quarterly basis and report any deficiencies to the Project Director. |
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 and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in three of four applicable client records reviewed. The facility policy manual stated that a follow-up call will be completed and documented within seven days of discharge.Client #11 was admitted to the outpatient activity on July 31, 2025 and was discharged on August 12, 2025. There was no follow-up information documented in the record at the time of the inspection. Client #12 was admitted to the outpatient activity on February 19, 2025 and was discharged on October 15, 2025. The follow-up information was to be completed no later than October 22, 2025; however, follow-up was completed and documented on November 24, 2025. Client #14 was admitted to the outpatient activity on February 10, 2025 and was discharged on March 28, 2025. The follow-up information was to be completed no later than April 4, 2025; however, follow-up was completed and documented on April 10, 2025. This is a repeat citation from the December 20, 2024 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
7 days following a client's discharge from Libertae, the therapist will attempt to contact the client via phone to determine her disposition status. Once the attempt at contact has been made and documented, the client chart will be considered complete.
This deficiency will be addressed by the Clinical Director, who will advise the clinical therapists of the expectation of contact and documented follow-up with each client who is discharged from Libertae within 7 days. This deficiency will be addressed on an ongoing basis by the Clinical Director, who will perform regular record reviews of completed charts to ensure that all closed charts are complete and accurate, to include contact following discharge.
This plan of correction shall be completed by 1/15/2026. Quarterly quality assurance meetings shall be held to ensure that the corrective action plan is being followed and implemented. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for not documenting case consultation notes in the client record were submitted and approved by the Department for the December 18, 2023 and December 20, 2024 annual licensing renewal inspections. Not documenting case consultation notes in the client records was again found to be a deficiency in the December 2, 2025 through December 3, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The repeated deficiency regarding case consultation documentation will be addressed by the Clinical Director implementing a formalized tool to assist clinical therapists in ensuring that case consultations are submitted within the 90 days required. Adherence to this process will be assessed in biweekly individual supervision sessions, in which case consultation notes and documentation will be reviewed for each active client on the therapist's caseload.
The Clinical Director and Project Director shall meet by January 15, 2026 to implement and complete this plan of correction. Follow up meetings will be held quarterly to ensure that the approved plan of corrections are being followed and implemented. |