INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 4, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Limitless Recovery 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 an attempted review of personnel records, the facility failed to document that Employee #1, who was hired as the project director and facility director on February 16, 2022, had the educational or experience requirements for the positions. There was no personnel file provided to DDAP staff during the inspection process and copies of the employee's degree, transcripts, resume, or written verification of education were also not provided; therefore, DDAP staff was unable to determine if the employee was qualified for the positions.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Program Director: has earned a Master's Degree (MA) in Professional Counseling from Liberty University in 2015 and can provide documented evidence of this fact. Furthermore, he is currently licensed with the State of Pennsylvania as a Licensed Professional Counselor (LPC) that requires a Master's Degree from an accredited university. License Number: PC009969 Exp. Date 2/28/23. He has also been approved by The PA State Credentialing Board (PCB) as a Certified Advanced Alcohol and Drug Counselor (CAADC) which also requires a Master's Degree form an accredited university. Certification Number: 9592 Exp. Date 5/10/22. An updated resume, copy of MA diploma, and copies of LPC, and CAADC will be included in employee file by 5/3/22 and be held in the directors office amd updated as needed. |
704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(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 clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on an attempted review of personnel records, the facility failed to document that Employee #2, who was hired as a clinical supervisor on February 16, 2022, had the educational or experience requirements for the position in one of one applicable employee. There was no personnel file provided to DDAP staff during the inspection process and copies of the employee's degree, transcripts, resume, or written verification of education were also not provided; therefore, DDAP staff was unable to determine if the employee was qualified for the position.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor. has earned a Master's Degree (MA) in Counseling Psych. from Rosemont College in 2019 and can provide documented evidence of this fact. Furthermore, he has provided Clinical Supervision for at least 3 years. The Clinical Supervisor is currently scheduled to take his CAADC Exam and has earned his LPC supervision hours. He will be applying for his LPC once he passes his CAADC exam. HIs LPC requires A Master's Degree and over 3000 of supervisor from an LPC. An updated resume, copy of MA diploma, transcripts, etc. will be included in employee file by 5/3/22 and be held in the directors office and updated as needed. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed. Employee #2 was hired as a clinical supervisor on February 16, 2022 and did not have a copy of the resume in the record to verify clinical supervision experience prior to being hired. There was no documentation of the clinical supervision core curriculum training on file at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Due to new staffing, this is a new Clinical Supervisor. He has earned a Master's Degree (MA) in Counseling Psych. from Rosemont College in 2019 and can provide documented evidence of this fact. Furthermore, he has provided Clinical Supervision for at least 3 years. The Clinical Supervisor is currently scheduled to take his CAADC Exam and has earned his LPC supervision hours. He will be applying for his LPC once he passes his CAADC exam. HIs LPC requires A Master's Degree and over 3000 of supervisor from an LPC. An updated resume, copy of MA diploma, transcripts, etc. will be included in employee file by 5/3/22 and be held in the directors office and updated as needed. He is scheduled to complete a Department-approved core curriculum in clinical supervision by 11/03/22. |
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 personnel records, the facility failed to ensure that the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months in that position in one of one applicable personnel record reviewed.Employee #2 was hired as a clinical supervisor on February 16, 2022. The personnel record did not include documented monthly clinical supervision meeting for the month of March 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director, will conduct individual supervisor with Clinical Supervisor for a min. or 1 hour per week and an additional monthly meeting for a min. of 1 hour.to discuss duties and performance. Clinical Program Director will document and sign off on each supervisory interaction (weekly/ monthly) and a require Clinical Supervisor to sign/ acknowledge supervision log. This log will be available in Clinical Supervisor's employee file. This process will start immediately and remain in place. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on an attempted review of personnel records, the facility failed to document that Employee #3, who was hired as a counselor on February 16, 2022, had the educational or experience requirements for the position in one of one employee reviewed. There was no personnel file provided to DDAP staff during the inspection process and copies of the employee's degree, transcripts, resume, or written verification of education were also not provided; therefore, DDAP staff was unable to determine if the employee was qualified for the position.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee # 3 is a new employee, as with all staff employed at Limitless Recovery, LLC. Employee #3's employee file has been updated with required documents that show educational and/ or experience requirements. Including but not limited to: Resume, copy of diploma for advanced degree, and/or transcript of Master's Degree program, and all required trainings. This is available immediately. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that each employee had a written, annual individual training plan, with input from the employee and supervisor, documented in the record in three of three personnel records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will develop, in collaboration with all clinical staff members, an annual training plan that must be completed within the annual training timeframe. The training plan must include at least 25 hours of training and will be agreed upon, signed off on by both the Clinical Program Director and each clinical staff member respective of their individualized annual training plan. Each training plan must include 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.
Clinicians will provide documentation/ certification of completion for this training, which will be placed in employee file. Clinical Program Director will monitor progress of training plans on a weekly basis during supervision.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.All three personnel records reviewed failed to have documentation of current CPR certifications and first aid trainings.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will mandate that CPR certification and first aid trainings be provided/ completed to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
All personnel records will have documentation of current CPR certifications and first aid trainings completed by 6/30/2022. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on an attempted review of personnel records, the facility failed to provide documentation that all staff were trained in the use of the fire extinguisher upon employment in three of three employees reviewed.There were no personnel files provided to DDAP staff during the inspection process and no copies of the use of fire extinguisher training was provided at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director has updated all employee files with current fire extinguisher training. Policy and Procedures Manual will be updated to include specific training related to approved fire extinguisher utilization, procedures related to fire emergencies and evacuations, including location of fire extinguishers, locations of building exits, and floor plans/ maps located in common areas to be used during fire emergencies/ evacuations. This will be completed during the first two-weeks of employment by all newly hired staff. All employee files that include these training and newly hired staff that complete these trainings are/ will be located on-site in the management office and are accessible for inspection.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the April 2021 through March 2022 fire drill logs, the facility failed to conduct an unannounced fire drill, at least one time a month, during every month reviewed.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Operations will execute monthly fire drills and document all imperative information (date, time, the amount of time it took for evacuation, the exit route used, and the number of persons in the facility at the time of the drill) in the Emergency Preparedness Binder located in the office of Director of Operations.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on an attempted review of personnel records, the facility failed to provide documentation that all personnel are trained to perform assigned tasks during emergencies upon employment in three of three employees reviewed.There was no personnel files provided to DDAP staff during the inspection process and no copies of the emergency preparedness training was provided at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations and Clinical Program Director can provide documentation that all personnel are trained to perform assigned tasks during emergencies. This training was given during an all staff orientation after Limitless Recovery, LLC was acquired. Training given on 3/1/2022. This training and respective assigned tasks, confirmed with signature, will be available in employee files. All new hires will be trained accordingly, within the first two-weeks of hire on assigned tasks during emergencies and signed training log will be placed in employee file. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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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. Plans of correction for keeping release of information forms within the limits established by 4 Pa. Code 255.5 (b) were submitted and approved by the Department for the April 1, 2021, February 28, 2020, and February 13, 2019 annual licensing inspections. Releases of information forms that exceeded the limits established by 4 Pa. Code 255.5 (b) were again found to be a deficiency in the April 4, 2022 licensing inspection. Plans of correction for follow-up information were submitted and approved by the Department for the April 1, 2021, February 28, 2020, and February 13, 2019 annual licensing inspections. Follow-up information was again found to be a deficiency in the April 4, 2022 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to a change of management and staff the Clinical Program Director has provided training with the assistance of Operations Manager, to all intake staff, to limit Releases of Information forms (ROI), as outlined 4 Pa. Code 255.5 (b). Furthermore, Clinical Program Director will require Operations Manager to conduct specific training related to ROI forms, signed confirmation for of the training for each new hire will be placed in their respective employee file. Forms that are currently active but are not limited to:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Post-Discharge Follow-ups for clients will be conducted every 30, 60, 90, and 120 days. This will be conducted by the Manager of Operations and documented in the clients' medical record. Follow-ups will help determine program efficacy via determination of abstinence, relapse potential, aftercare follow-through, evaluation for re-engagement with clinical programming, anecdotes/ personal success testimonials, and possible referrals/ resources to assist with any identified social determinants of health. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project failed to ensure that the project director annually updated and signed the written manual delineating the project's policies and procedures. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
New Clinical Program Director will annually update and sign the developed the project's written Policy and Procedures manual with required updates based on DDAP citations. |
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 facility failed to 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. The facility has an exception, per Licensing Alert 01-11, however, the project failed to provide the most recent tax return, in accordance with the exception.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Limitless Recovery, LLC; CEO, will obtain and provide documentation of 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 and provide the most recent tax return when received from the IRS, but the tax return may occur after the next scheduled inspection in 6 months. |
709.26 (b) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(1) Application or resume for employment.
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Observations
Based on an attempted review of personnel records, the facility failed to document that all employees had an application or resume for employment in three of three employees reviewed. There was no personnel file provided to DDAP staff during the inspection process and copies of the employee's application or resume were not provided at the time of the inspection.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Program Director has updated employee/ personnel files with/ but not limited to copies of resumes, applications, trainings, credentials, diplomas licenses, and any documents pertaining to job responsibilities and qualifications.. These files are readily available for the next DDAP inspection. Furthermore, Clinical Program Director will require each new hire to provide copies of resumes, applications, trainings, credentials, diplomas, licenses, and any documents pertaining to job responsibilities and qualifications. These documents will be placed in each employee file, respectively. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to document that all employees had written verification of qualifying professional credentials in three of three employees reviewed. There was no personnel file provided to DDAP staff during the inspection process and copies of the written verification of employee's qualifying credentials were not provided at the time of the inspection.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Program Director has updated employee/ personnel files with/ but not limited to copies of resumes, applications, trainings, credentials, diplomas, licenses, and any documents pertaining to job responsibilities and qualifications. These documents will be placed in each employee file, respectively. These files are readily available for the next DDAP inspection. Furthermore, Clinical Program Director will require each new hire to provide copies of resumes, applications, trainings, credentials, diplomas, licenses, and any documents pertaining to job responsibilities and qualifications. These documents will be placed in each employee file, respectively. |
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 project 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 #1 was admitted on March 14, 2022 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on March 14, 2022 that allowed for the release of psychosocial data and assessment, discharge summary, all clinical progress notes and treatment plans, and all correspondence contained in the record, which exceeded the limits established by 4 Pa. Code 255.5.Client #2 was admitted on March 30, 2022 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on March 30, 2022 that allowed for the release of the psychosocial data and assessment, discharge summary, and all clinical progress notes and treatment plans, which exceeded the limits established by 4 Pa. Code 255.5.Client #4 was admitted on July 13, 2021 and was discharged on January 7, 2022. A release of information form to a funding source was signed and dated by the client on July 13, 2021 that allowed for the release of the psychosocial data and assessment, which exceeded the limits established by 4 Pa. Code 255.5.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to a change of management and staff the Clinical Program Director has provided training with the assistance of Operations Manager to intake staff to utilize Release of Information (ROI) forms established by 4 Pa. Code 255.5 (b). Furthermore, Clinical Program Director and Operations Manager will ensure all new hires be trained on the proper ROI requirements and indications for release on the ROI forms established by 4 Pa. Code 255.5. Signed confirmation of this training will be placed in each respective file for new hires. Client # 1 and # 2 will sign an amended ROI forms related to ROI to funding source; psychosocial data and assessment, discharge summary, all clinical progress notes and treatment plans. Client # 4 has been discharged and is unavailable to sign an amended ROI for funding source. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgment by clients that they had been notified of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, in all seven client records reviewed. The written acknowledgement form was missing ethnicity and marital status.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to a change of management and staff, the Clinical Program Director has provided training with the assistance of Operations Manager to intake staff to notify all clients of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, or handicap or religion. All current clients will sign a Civil Rights Compliance form in the electronic medical record affirming that they were informed of the aforementioned rights. Furthermore, Clinical Program Director will ensure the continuation of this requirement through weekly chart audits for all new and existing clients and mandate corrections if necessary. All new hires will be trained on the administration and completing signature confirmation of Civil Rights with each incoming/ new client. A signed confirmation to this training will be placed in the respective employee file. |
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, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in four of four applicable client records reviewed.Client #4 was admitted on July 13, 2021 and was discharged on January 7, 2022. There was no follow-up documentation in the record at the time of the inspection.Client #5 was admitted on June 10, 2021 and was discharged on September 28, 2021. There was no follow-up documentation in the record at the time of the inspection.Client #6 was admitted on April 5, 2021 and was discharged on June 18, 2021. There was no follow-up documentation in the record at the time of the inspection.Client #7 was admitted on October 4, 2021 and was discharged on March 18, 2022. There was no follow-up documentation in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the April 1, 2021, February 28, 2020, and February 13, 2019 annual licensing inspections.
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Plan of Correction
Clinical Program Director will conduct weekly chart audits of the electronic medical record (EMR) to ensure that all clients in the clinical program to a maintain a complete client record on an individual, which is to include follow-up information. The identified clients are no longer enrolled in the program but all client charts will be reviewed and adjusted/ amended as part of the weekly audit. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the hours of operation for the project were displayed conspicuously to the general public.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Operations Manager has posted hours of operation for the project and displayed them for viewing from the general public.
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to ensure an emergency telephone number was displayed conspicuously to the general public.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Operations Manager has ensured an emergency telephone number is currently displayed for viewing from the general public. |