INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12, 2024 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of July 2023 through May 2024, the facility failed to prepare alternate exit routes to be used during fire drills. All exits documented were the " emergency exit. "
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide on-site training related to use of alternate routes during monthly fire drills and documentation of those routes. Training information will be maintained on site for review and Director and/or Clinical Supervisor will monitor for on-going compliance as indicated with initials on the completed forms. Staff training will be completed by 8/15/24. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill log for the months of July 2023 through May 2024, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts. All fire drills were conducted between 11:00am and 12:30pm.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide on-site training related varying the time of the monthly fire drills and documentation of the varied times. Training information will be maintained on site for review and Director and/or Clinical Supervisor will monitor for on-going compliance as indicated with initials on the completed forms. Staff training will be completed by 8/15/24. |
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 #2 was admitted on November 1, 2023 and still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 24, 2023. A treatment and rehabilitation plan update was due no later than March 24, 2024, but was not completed until March 28, 2024.
A treatment and rehabilitation plan was developed on March 28, 2024. A treatment and rehabilitation plan update was due no later than May 28, 2024, but was not completed until June 5, 2024.
Client #5 was admitted on February 1, 2024 and was discharged on May 28, 2024. A treatment and rehabilitation plan was developed on February 29, 2024. A treatment and rehabilitation plan update was due no later than April 29, 2024, but was not completed until May 2, 2024.
Client #7 was admitted on October 25, 2023 and was discharged on June 5, 2024. A treatment and rehabilitation plan was developed on March 21, 2024. A treatment and rehabilitation plan update was due no later than May 21, 2024, but was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 13, 2023 annual licensing inspection.
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Plan of Correction
Clinical Supervisor will provide on-site training related to Treatment Planning and Treatment Plan Updates specifically focused on 60 day timeframe for completion. Clinical Supervisor will also work with counselors during supervision to assist in ensuring timely documentation. Training information will be maintained on site for review. Clinical Supervisor will monitor for on-going compliance as indicated with signatures on the completed treatment plans. Staff training will be completed by 8/15/24. |