INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on September 6, 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, met the education and 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 is a repeat citation from the April 4, 2022 annual licensing renewal inspection.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 and 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, met the education and 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 is a repeat citation from the April 4, 2022 annual licensing renewal inspection.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 10/5/22
and be held in the directors office
and updated as needed. |
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 the 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 months of April 2022, May 2022, June 2022, July 2022, and August 2022.This is a repeat citation from the April 4, 2022 annual licensing renewal inspection.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, met the education and experience requirements for the position in one of three applicable employees reviewed. One of three applicable personnel files was not 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 employee #3 was qualified for the position. The two personnel files that were reviewed did include documentation of education and experience requirements.This is a repeat citation from the April 4, 2022 annual licensing renewal inspection.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 an attempted 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 all five employees reviewed.This is a repeat citation from the April 4, 2022 annual licensing renewal inspection.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. |
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 five employees reviewed.Three of five personnel files were not provided to DDAP staff during the inspection process and no copies of the use of fire extinguisher training were provided at the time of the inspection. The two files that were reviewed did include documentation of fire extinguisher training.This is a repeat citation from the April 4, 2022 annual licensing renewal 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. |
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 2022 through August 2022 fire drill logs, the facility failed to conduct an unannounced fire drill, at least one time a month, during every month reviewed.This is a repeat citation from the April 4, 2022 annual licensing renewal inspection.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(minimum 1x per month)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.
The Clinical Program Director will audit the "Emergency Preparedness Binder" quarterly to assure compliance. |
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 in three of five employees reviewed.Three of five personnel files were not provided to DDAP staff during the inspection process and no copies of the emergency preparedness training were provided at the time of the inspection. The two files that were reviewed did include documentation of emergency preparedness training.This is a repeat citation from the April 4, 2022 annual licensing renewal 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.
Clinical Program Director will audit employee files within 30 days of a new hire to assure all required documentation has been collected and placed in appropriate employee file. New employees will have 72 hours to produce any missing, incomplete, or incorrect documents discovered during audits. |
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 is a repeat citation from the April 4, 2022 annual licensing renewal inspection.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 the project's written
Policy and Procedures manual with
required updates based on DDAP
citations. For annual DDAP audit review.
Clinical Program Director, COO, Clinical Supervisor, and Director of Operations will meet quarterly to review Policy & Procedures and make any necessary edits/ updates for the purposes of patient safety, functionality of operations, and DDAP compliance. |
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 five employees reviewed. Three of five personnel files were not 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. The two files that were reviewed did include documentation of resumes for employment.This is a repeat citation from the April 4, 2022 annual licensing renewal 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
Clinical Program Director will audit all new employee files within 30 days of hire and request any outstanding documentation or updated/ corrected documents within 72 hours of discovery. |
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 five employees reviewed. Three of five personnel files were not 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. The two files that were reviewed did include documentation of qualifying professional credentials.This is a repeat citation from the April 4, 2022 annual licensing renewal 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
Clinical Program Director will audit all new employee files within 30 days of hire and request any outstanding documentation or corrected/ updated documentation within 72 hours of discovery. |