INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4, 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 that the project and facility director met the qualifications of the position at the time of hire in 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. Meetings will occur monthly with an estimaged 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 25, 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.
7. 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 25, 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 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 25, 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.
3. Results of evaluations will be used to guide future training needs assessments and annual training plans.
4. Annual calendar reminders have been established to ensure completion by January 31st.
5. Senior Leadership will annually verify completion and implementation.
6. The Clinical Supervisor will maintain documentation of evaluations and report findings to Senior Leadership annually.
7. For the year 2026, all staff training needs assessments have been reviewed and outlined for the remainder of 2026.
8. A specialized meeting has been established to occur annually in January with Senior Leadership and the clinical team. Planned date of this review meeting is 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 three 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: 50.5/35=1.44 (FTE); 69/1.44 = 47.91, which equals to a client/counselor ratio of 47:1.
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 6 hours per week devoted to their 10 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 6/35 = .17(FTE); 10/.17 = 58.82, which equals to a client/counselor ratio of 58:1.
Staff #5 was hired as a counselor on May 5, 2025 and was still in this position at the time of the inspection. Staff #5 was reported to have 29 hours per week devoted to their 46 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 29/35 = .82(FTE); 46/.82 = 56.09, which equals to a client/counselor ratio of 56:1.
Staff #6 was hired as a counselor on April 13, 2026 and was still in this position at the time of the inspection. Staff #6 was reported to have 8 hours per week devoted to their 8 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 8/35 = .22(FTE); 8/.22 = 36.36, which equals to a client/counselor ratio of 36:1.
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 five of seven records. The facility ' s policy states the initial comprehensive treatment and rehabilitation plan will be developed with the client within thirty days of admission.
Client #2 was admitted on October 2, 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 November 2, 2025; however, this was not completed until November 20, 2025.
Client #3 was admitted on January 29, 2026 and was still active at the time of the inspection.
The initial comprehensive treatment and rehabilitation plan completed on February 26, 2026 did not include documentation of the plan being developed with the client.
Client #4 was admitted on September 22, 2025 and was discharged on May 20, 2026.
The initial comprehensive treatment and rehabilitation plan completed on October 22, 2025 did not include documentation of the plan being developed with the client.
Client #5 was admitted on February 16, 2026 and was discharged on April 30, 2026.
The initial comprehensive treatment and rehabilitation plan was due to be completed no later than March 18, 2026; however, this was not completed prior to discharge.
Client #6 was admitted on July 15, 2025 and was discharged on December 8, 2025.
The initial comprehensive treatment and rehabilitation plan was due to be completed no later than August 15, 2025; however, this was not completed until August 19, 2025. 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 four of six applicable records.
Client #1 was admitted on September 3, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on March 19, 2026. The next treatment and rehabilitation plan update was due no later than May 19, 2026; however, this was not completed until May 21, 2026.
Client #3 was admitted on January 29, 2026 and was still active at the time of the inspection.
A treatment and rehabilitation plan was developed on February 26, 2026. A treatment and rehabilitation plan update was due no later than April 26, 2026; however, this was not completed at the time of the inspection.
Client #4 was admitted on September 22, 2025 and was discharged on May 20, 2026. A treatment and rehabilitation plan was developed on October 22, 2025. A treatment and rehabilitation plan update was due no later than December 22, 2025; however, this was not completed until December 31, 2025.
Additionally, a treatment and rehabilitation plan update was completed on February 22, 2026. The next treatment and rehabilitation plan update was due no later than April 24, 2026; however, this was not completed until April 28, 2026.
Client #7 was admitted on July 31, 2025 and was discharged on April 23, 2026.
A treatment and rehabilitation plan update was completed on December 23, 2025. A treatment and rehabilitation plan update was due no later than February 23, 2026; however, this was not completed until February 25, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 13, 2023, June 12, 2024, and June 25, 2025 annual licensing inspections.
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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. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to ensure the clients received counseling services according to their individual treatment plan in two of six applicable records.
Client #4 was admitted on September 22, 2025 and was discharged on May 20, 2026. The treatment plan dated October 22, 2025 indicated one hour of individual therapy sessions monthly. The following treatment plan updates did not change the frequency of counseling services. There was no documentation of the client receiving individual therapy between March 1-April 30.
Client #7 was admitted on July 31, 2025 and was discharged on April 23, 2026.
The treatment plan update dated December 23, 2025 indicated one hour of individual therapy sessions bi-weekly. There was no documentation that the client received individual sessions between January 11-April 23.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Project Director and Clinical Supervisor reviewed findings with counselors regarding adherence to treatment plan frequencies.
2. All active client records were audited to verify that counseling services are being provided at the frequency identified in each client's individualized treatment and rehabilitation plan.
3. Any discrepancies identified during the audit were corrected immediately through scheduling of services or documented clinical revisions to the treatment plan when clinically appropriate.
4. Clinical staff received retraining on DDAP regulations, agency policy, and documentation requirements to ensure counseling services are provided according to each client's individualized treatment and rehabilitation plan.
5. Counseling service review and tracking has been implemented to monitor required counseling frequencies for all active clients.
6. Specific areas of monitoring include by are not limited to scheduled due dates for individual counseling sessions and clients who are approaching or exceeding the required interval between sessions.
7. The Clinical Supervisor will review counselor schedules and counseling frequency reports during Supervision, both as Group and Individually, to ensure services are provided as prescribed.
8. Monthly chart review and/or discussion will be conducted to verify compliance with treatment plan requirements. |
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 five 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 #1 was admitted on September 3, 2025 and was still active at the time of the inspection. The three-month case consultation was due to occur no later than December 3, 2025; however, this was not completed until December 9, 2025.
Client #2 was admitted on October 2, 2025 and was still active at the time of the inspection.
The six-month case consultation was due to occur no later than April 2, 2026; however, this was not completed at the time of the inspection.
Client #3 was admitted on January 29, 2026 and was still active at the time of the inspection.
The three-month case consultation was due to occur no later than April 29, 2026; however, this was not completed at the time of the inspection.
Client #4 was admitted on September 22, 2025 and was discharged on May 20, 2026. The three-month case consultation was due to occur no later than December 22, 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 22, 2026; however, this was not completed at the time of the inspection.
Client #7 was admitted on July 31, 2025 and was discharged on April 23, 2026.
The six-month case consultation was due to occur no later than January 31, 2026; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 25, 2025 annual licensing inspection.
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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. |
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 applicable client records reviewed, the facility failed to complete an aftercare plan in accordance with the facility policy and procedure manual in one of one records. The facility policy and procedure manual indicated an aftercare plan will be completed with the client for all planned discharges.
Client #6 was admitted on July 15, 2025 and was discharged on December 8, 2025. An aftercare plan 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. FHS has reviewed the active client records to identify/plan for anticipated planned discharges to verify that aftercare plans are completed before discharge.
2. Clinical staff received retraining on discharge planning requirements, including completion of individualized aftercare plans for all planned discharges.
3. The Clinical Supervisor will conduct monthly discharge chart audits to verify compliance and provide corrective coaching when deficiencies are identified. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in one of one records. The policy and procedure manual indicates follow-up contact must be made within ninety days of discharge.
Client #6 was admitted on July 15, 2025 and was discharged on December 8, 2025. The follow-up contact was due to be completed no later than March 8, 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. FHS revised the discharged policy.
2. Staff education and supervisory review were completed.
3. All discharged client records requiring follow-up contact were audited to verify compliance with agency policy.
4. The Patient Care Coordination Team is responsible for pulling the Monthly Discharge Report to identify all discharged clients requiring ninety-day follow-up contact and to monitor completion dates.
5. Calendar reminders have been established to notify Patient Care Coordinators of upcoming follow-up deadlines.
6. The Clinical Supervisor will follow-up with the Patient Care Coordinator(s) to ensure follow-up contacts are completed and documented in accordance with agency policy. |
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 treatment plan updates was submitted and approved by the Department for the June 13, 2023, June 12, 2024, and June 25, 2025 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the June 4, 2026 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. FHS reviewed all previously approved Plans of Correction related to treatment planning and evaluated why sustained compliance was not achieved.
2. A comprehensive audit of all active client records was completed to ensure treatment plans and treatment plan updates are completed within required timeframes and in accordance with DDAP regulations and agency policy.
3. The Project Director and Clinical Supervisor have revised the Quality Assurance process to include monthly audits of all regulatory areas cited during previous licensing inspections.
4. Clinical staff received retraining on treatment planning requirements, documentation standards, and the importance of maintaining continuous compliance with approved Plans of Correction.
5. The Project Director will attend at least one Group Supervision meeting to corrective actions remain effective and recurring deficiencies are identified and addressed immediately.
6. Senior Leadership Committee will audit the monthly findings to ensure compliance. First review meeting is scheduled for 7/21/2026. These reviews will take place for a minimum of 6 months, with additional consideration upon the term on 12/31/2026. |