INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2025 through March 7, 2025 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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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in two of ten client records reviewed.
Client #5 was admitted to the partial hospitalization level of care on November 18, 2024 and was a current client in the outpatient level of care at the time of the inspection. A release of information form for an emergency contact, signed by the client on November 7, 2024, did not specify the information to be disclosed.
Client #8 was admitted on March 25, 2024 and was discharged on June 21, 2024. A release of information form for a mental health professional, signed by the client on March 25, 2024, did not specify the information to be disclosed.
This is a repeat citation from the January 18, 2024, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Client #5 is an active client and his release of information for his emergency contact was corrected on 3/21/25 to specify the information to be disclosed.
Client #8 was discharged on 6/21/24 and his release of information for a mental health professional, by default per our policy, expired 6 months after discharge which was 12/21/24. Therefore, correction of deficiency to this particular release is no longer needed.
Facility Director conducted training with administrative and clinical staff on 3/21/25, specifically addressing the proper completion of the release forms, including the specific information
to be disclosed.
Facility Director will implement a new chart review process for a weekly audits to ensure compliance. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of ten client records reviewed.
Client #8 was admitted on March 25, 2024 and was discharged on June 21, 2024. A release of information form for a mental health professional, signed by the client on March 25, 2024, did not specify the purpose of disclosure.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Client #8 was discharged on 6/21/24 and his release of information for a mental health professional, by default per our policy, expired 6 months after discharge which was 12/21/24. Therefore, correction of deficiency to this particular release is no longer needed.
Facility Director conducted training with administrative and clinical staff on 3/21/25, specifically addressing the proper completion of the release forms, including the purpose of disclosure.
Starting 4/14/25, Facility Director/Supervisor will implement a new chart review process for a weekly audit to ensure compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on the review of partial hospitalization client records, the facility failed to review and update treatment and rehabilitation plans at least every 30 days in one of one applicable client record reviewed.
Client #1 was admitted on August 19, 2024 and was discharged on November 11, 2024. An updated treatment and rehabilitation plan was documented in the record on September 18, 2024, and the update was due no later than October 18, 2024; however, the treatment plan update was not documented in the record until November 11, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director conducted a staff training about treatment plan to all clinical staff members on 3/21/25.
The training focuses on the adherence of care delivery to our clients according to their treatment plan as well as the review and update of treatment plan every 30 days for clients who are in the PHP level of care.
The Facility Director will implement a new chart review process starting 4/14/25 and perform a weekly audit to ensure the treatment plan is reviewed and updated every 30 days in PHP level of care. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the project failed to document two weekly individual counseling sessions in four of seven partial hospitalization clients reviewed.
Client #2 was admitted on October 2, 2024 and was discharged on November 4, 2024. The project only documented one individual counseling session for the week of October 6, 2024 through October 12, 2024.
Client #3 was admitted on October 1, 2024 and was discharged on October 30, 2024. The project only documented one individual counseling session for the weeks of October 6, 2024 through October 12, 2024 and October 13, 2024 through October 19, 2024.
Client #4 was admitted on May 7, 2024 and was discharged on June 10, 2024. The project only documented one individual counseling session for the week of May 26, 2024 through June 1, 2024.
Client #7 was admitted on June 19, 2024 and was discharged on July 17, 2024. The project only documented one individual counseling session for the week of July 7, 2024 through July 12, 2024. Additionally, the project did not document any individual counseling sessions for the week of June 30, 2024 through July 6, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director conducted a staff training about care delivery and client records policies to all clinical staff members on 3/21/25.
The training focused on the adherence of care delivery requirements according to the treatment plan at the Partial Hospitalization level of care including 2x individual counseling weekly. This training also discussed the importance of documentation when the client is absent from the individual counseling at the scheduled individual counseling appointment.
The Facility Director will implement a new chart review process starting 4/14/25 and will perform a weekly audit of all progress notes at PHP level of care to ensure compliance. |
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 project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in six out of nine applicable client records reviewed.
Client #10 was admitted on November 4, 2024 and was discharged on January 7, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on November 3, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of November 24, 2024 through November 30, 2024 and December 22, 2024 through December 28, 2024.
Client #12 was admitted on June 10, 2024 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on June 10, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of December 22, 2024 through December 28, 2024 and December 29, 2024 through January 4, 2024.
Client #13 was admitted on December 13, 2024 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on December 13, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of December 29, 2024 through January 4, 2025 and February 9, 2025 through February 15, 2025.
Client #14 was admitted on July 17, 2024 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on July 17, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of July 21, 2024 through July 27, 2024 and September 15, 2024 through September 21, 2024. Additionally, an updated treatment and rehabilitation plan, documented in the client record on October 29, 2024, indicated that the client was to receive two individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of December 22, 2024 through December 28, 2024 and December 29, 2024 through January 4, 2024; and, there was only one individual counseling sessions documented in the client record for the weeks of January 26, 2025 through February 1, 2025 and February 16, 2025 through February 22, 2025.
Client #15 was admitted on March 4, 2024 and was discharged on November 22, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on March 4, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of March 3, 2024 through March 9, 2024, March 24, 2024 through March 30, 2024 and March 31, 2024 through April 6, 2024.
Client #16 was admitted on March 26, 2024 and was discharged on July 27, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on March 26, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of March 31, 2024 through April 6, 2024, April 7, 2024 through April 13, 2024, May 12, 2024 through May 18, 2024, May 19, 2024 through May 25, 2025, June 9, 2024 through June 15, 2024, June 16, 2024 through June 22, 2024, June 23, 2024 through June 30, 2024, June 30, 2024 through July 6, 2024, July 7, 2024 through July 13, 2024 and July 14, 2024 through July 20, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director conducted a staff training about care delivery and client records policies to all clinical staff members on 3/21/2025.
The training focused on the adherence of care delivery requirements according to the treatment plan at the IOP level of care including 1x individual counseling weekly. This training also discussed the importance of documentation when the client is absent, be it excused or unexcused, from the individual counseling at the scheduled individual counseling appointment.
The Facility Director will implement a new chart review process starting 4/14/25 and will perform a weekly audit of all progress notes at IOP/OP level of care to ensure compliance. |