INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 1, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Providence Living LLC d/b/a Providence Treatment 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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704.12(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 Requirement Facility Summary Report, the facility failed to ensure that the FTE counselor caseload in outpatient programs did not exceed 35 active clients in two of six applicable counselors reviewed.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #3 was hired as a counselor on March 1, 2019 and was still employed at the time of the inspection. Their ratio calculation was as follows: 2/40 = .075(FTE); 2/.05 = 40 which equals a client/counselor ratio of 40:1.
Employee #4 was hired as a counselor on March 27, 2018 and was still employed at the time of the inspection. Their ratio calculation was as follows: 3/40 = .05(FTE); 3/.075 = 40 which equals a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 and #4 are assigned to this location on a part time basis. They have been assigned to another location to meet the remaining FTE hours.
To maintain the appropriate client to counselor ratio, Providence Treatment has increased clinical staff to support the client needs at this location. The facility director will be responsible to monitor the counselor's ratio going forward. |
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 a review of the facility's March 2021 through February 2022 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's hours of operation are Monday through Friday 9:00AM - 9:00PM. All the fire drills conducted, during the reviewed period, were completed during the morning and afternoon hours of operation. None of the drills were conducted during the facility ' s evening hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding fire drills, the Facility Director shall ensure that fire drills are conducted during daytime and evening hours of operation. The Facility Director shall audit the fire drills and their times quarterly and report to the Leadership Committee about their compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in six of seven client records reviewed.
First, the policy and procedure manual stated that the comprehensive treatment plan will be completed within 14 days of admission.
Client #2 was admitted on January 12, 2022 and was active at the time of inspection. The comprehensive treatment plan was due no later than January 26, 2022; however, the plan was signed and completed by the counselor on February 16, 2022.
Client #3 was admitted on July 21, 2021 and was discharged on October 15, 2021. The comprehensive treatment plan was due no later than August 4, 2021; however, the plan was signed and completed by the counselor on August 17, 2021. Also, the written procedure manual stated that aftercare plan will begin at treatment and reviewed with the client throughout treatment. The aftercare plan was completed post discharge and signed by the counselor on October 25, 2021.
Second, the policy and procedure manual stated that case consultation notes will be completed at least every 90 days.
Client #4 was admitted on October 16, 2019 and was discharged on July 20, 2021. A case consultation was documented on August 7, 2019, and no other case consultations were documented prior to discharge.
Client #6 was admitted on August 28, 2018 and was discharged on January 24, 2022. A case consultation was documented on September 18, 2020, and no other case consultations were documented prior to discharge.
Client #7 was admitted on August 28, 2017 and was discharged on July 21, 2021 (according to the discharge summary). A case consultation was documented on September 13, 2019, and no other case consultations were documented prior to discharge.
Third, the policy and procedure manual stated that aftercare plans will begin at treatment and be reviewed with the client throughout treatment.
Client #5 was admitted on May 11, 2020 and was discharged on September 9, 2021. The aftercare plan was completed post-discharge and was signed by the counselor on September 23, 2021.
Client #7 was admitted on August 28, 2017 and was discharged on July 21, 2021 (according to the discharge summary). The aftercare plan was completed post-discharge and was signed by the counselor on July 24, 2021
Finally, the policy and procedure manual stated that follow-up information will occur within 7 days of discharge.
Client #7 was admitted on August 28, 2017 and was discharged on July 21, 2021 (according to the discharge summary). The follow-up information was documented on July 31, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #2 and #3. Facility Director will meet with primary counselors in supervision to ensure proper completion of the comprehensive treatment plans and aftercare planning for each of their clients.
Clients #4, #6 and #7. Facility Director will work with primary counselors to present case consultations in weekly staff meetings and complete the required documentation (The Consultation Report) and file the report into the client's chart.
Clients #5 and #7. Facility Director will meet with all primary counselors to instruct them about the aftercare planning policy. All aftercare planning documentation will be completed prior to all planned discharges.
Facility Director will conduct a quarterly audit with all discharged clients within the quarter to ensure aftercare planning compliance. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An audit of our financials for 2020-2021 will be conducted and a CPA audit report shall completed by May 31, 2022. This will include an opinion by the Certified Public Accountant (CPA) that the facility's financial statements, the financial position and the results of the operations of the organization presents fairly.
Going forward the COO will be responsible to ensure compliance with an annual audit, completed by the CPA, each year by May 31st. |
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 seven client records reviewed.
Client #5 was admitted on May 11, 2020 and was discharged on September 9, 2021. A release of information form to the funding source was signed and dated by the client on May 11, 2020, which had an expiration date of May 11, 2021. There was documentation of disclosures to the funding source from May 12, 2021 through discharge. However, an updated consent to release information form to the funding source was not documented in the record prior to the disclosures after May 12, 2021.
Client #6 was admitted on August 28, 2018 and was discharged on January 24, 2022. A release of information form to the funding source was signed and dated by the client on May 28, 2019, which had an expiration date of May 28, 2020. There was documentation of disclosures to the funding source from May 29, 2020 through discharge. However, an updated consent to release information form to the funding source was not documented in the record prior to the disclosures after May 28, 2020. Additionally, a release of information form to a family member/emergency contact was signed and dated by the client on September 11, 2018, which had an expiration date of September 11, 2019. There was documentation of family sessions occurring on April 5, 2021, May 2, 2021, June 27, 2021, and September 19, 2021 and there was no updated consent to release information form to the family member/emergency contact documented in the record prior to the disclosures.
Client #7 was admitted on August 28, 2017 and was discharged on July 21, 2021 (according to the discharge summary). A release of information form to the funding source was signed and dated by the client on February 12, 2020, which had an expiration date of February 12, 2021. There was documentation of disclosures to the funding source from February 13, 2021 through discharge. However, an updated consent to release information form to the funding source was not documented in the record prior to the disclosures after February 12, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #5, #6 and #7. In regards to disclosures of information to funding sources, we revised our policies to reflect the ROI to expire sixty (60) days post-discharge. The Facility Director will train all staff on this topic (scheduled on 4/8/22). The Facility Director will conduct a quarterly audit of 50% of all admissions in the quarter to ensure completion and compliance. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of seven client records reviewed.
Client #2 was admitted on January 12, 2022 and was active at time of inspection. A release of information form to the funding source was signed and dated by the client on January 13, 2022 and allowed for the release of psychiatric and psychological evaluations, psychosocial assessment, consultation reports, laboratory results, psychometric testing report/results, discharge summary and medication records, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on July 21, 2021 and was discharged on October 15, 2021. A release of information form to the funding source was signed and dated by the client on July 21, 2021 and allowed for the release of psychiatric and psychological evaluations, psychosocial assessment, laboratory results, psychometric testing report/results, discharge summary and medication records, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on October 16, 2019 and was discharged on July 20, 2021. A release of information form to the funding source was signed and dated by the client on April 21, 2021 and allowed for the release of psychiatric and psychological evaluations, psychosocial assessment, consultation reports, laboratory results, psychometric testing report/results, discharge summary and medication records, all of which exceeded the limits established by 4 Pa. Code 255.5.
This is a repeat citation from the March 11, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #2, #3 and #4. In regards to disclosure of information, please see revised ROI for a) judges, b) probation officers, c) insurance companies, d) employers and e) government officials to meet 4 Pa. Code 255.5. The Facility Director will provide training to all staff on 4/8/22 for the new ROI form and update policy and procedure regarding this topic.
The Facility Director will conduct a quarterly audit of 50% of all new admissions during the quarter to ensure proper ROIs were used in compliance with our policies and procedures. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission dates and discharge dates within a specific time period requested.
The facility was unable to produce/identify clients ' admission and discharge dates between this licensed facility and the project ' s second licensed facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding admission and discharge recordkeeping of clients from various levels of care and between separate offices that provide care as Providence Treatment, the Project Director provided training to all clinical staff on proper recordkeeping in our EMR system when changing a client's level of care, or changing locations of service. The Facility Director will conduct an audit weekly with each clinician in supervision to ensure compliance with this standard. |
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 develop the individual comprehensive treatment and rehabilitation plan with the client in three of seven client records reviewed.
Client #1 was admitted on December 30, 2021 and was active at the time of inspection. The comprehensive treatment plan was signed and dated by facility staff on January 9, 2022. There was documentation that the comprehensive treatment plan was reviewed with the client on January 18, 2022; thus, indicating that the plan was not developed with the client's input.
Client #2 was admitted on January 12, 2022 and was active at the time of inspection. The comprehensive treatment plan was signed and dated by facility staff on February 16, 2022. There was documentation that the comprehensive treatment plan was reviewed with the client on February 18, 2022; thus, indicating that the plan was not developed with the client's input.
Client #3 was admitted on July 21, 2021 and was discharged on October 15, 2021. The comprehensive treatment plan was signed and dated by facility staff on August 17, 2021. There was documentation that the comprehensive treatment plan was reviewed with the client on August 5, 2021, which was prior to the development of the comprehensive treatment plan; thus, indicating that the plan was not developed with the client's input.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1, #2 and #3. In regards to their comprehensive treatment plan, all clients will meet with their assigned counselor to develop, compose and approve the Master Treatment Plan, with an attestation form to indicate their participation in the process.
The Facility Director will provide treatment planning training on 4/8/22 to all clinical staff. This training will include all revised policies and procedures. The Facility Director will conduct a quarterly audit to ensure compliance and client's input with regards to treatment planning standard and policies. |
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 a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in four of six applicable client records reviewed.
Client #4 was admitted on October 16, 2019 and was discharged on July 20, 2021. A treatment plan update was completed on April 9, 2021, and the next update was due no later than June 9, 2021; however, the finalized treatment plan update was signed and dated by the counselor on June 15, 2021.
Client #5 was admitted on May 11, 2020 and was discharged on September 9, 2021. A treatment plan update was completed on March 24, 2021, and the next update was due no later than May 24, 2021; however, the finalized treatment plan update was signed and dated by the counselor on May 30, 2021. The next treatment plan update was due no later than July 30, 2021; however, the finalized treatment plan update was signed and dated by the counselor on August 5, 2021.
Client #6 was admitted on August 28, 2018 and was discharged on January 24, 2022. A treatment plan update was completed on July 7, 2021, and the next update was due no later than September 7, 2021; however, the finalized treatment plan update was signed and dated by the counselor on October 7, 2021. Additionally, the next treatment plan update was due not later than December 7, 2021; however, it was not completed prior to discharge.
Client #7 was admitted on August 28, 2017 and was discharged on July 21, 2021 A treatment plan update was completed on March 28, 2021, and the next update was due no later than May 28, 2021; however, the finalized treatment plan update was signed and dated by the counselor on May 30, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #4, #5, #6 and #7. Regarding treatment plan updates, the Facility Director shall provide training on treatment planning that includes review and update timelines on April 8, 2022. The Facility Director shall conduct a quarterly audit on treatment planning and updates. Any cases not in compliance shall be documented in a performance supervision session with the clinician. |