INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2024 through September 11, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Promont 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 a review of personnel records, the facility failed to ensure the project director and the facility director met the appropriate experiential qualifications for the position in one of one applicable personnel record reviewed.
Employee #1 was hired as the project director/facility director on September 2, 2024. The personnel record documented the employee had obtained a qualifying master's degree; however, the employee did not have any documented experience in the supervision of others or program planning prior to being hired.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director name along with proper documentation of required qualifications will be provided for next inspection |
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 facility failed to ensure that the project director annually updated and signed the written manual, which delineates the project policies and procedures.
There was no documentation provided indicating the manual was reviewed, updated, and signed by the project director.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual was reviewed on 9/18/24 by Clinical Director. Documentation of the review was created and signed. Clinical Director will review Policy and Procedure Manual annually, document the review, as well as document any changes made to the manual. |
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 2023 fiscal year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CEO submitted request for exception on 9/13/24 and 9/18/24 via e-mail related to financial audit for 2023 fiscal year
CEO will continue to communicate with DDAP and comply with any requirements based on exceptions being granted or denied by next inspection.
CEO and directors of business development will continue to ensure all financial audits required and not granted exception will be completed and documentation will provided as needed |
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 project failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in fourteen of fourteen client records reviewed.
In every client record reviewed, there was evidence of disclosures to the funding source during each client ' s treatment episode; however, there were no client-signed consent to release information forms documented in any of the records prior to the disclosures of information.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Release of Information (255.5) for insurance providers was added to intake workflow and provided to all clinical staff.
Present clients have signed releases of information for insurance providers via primary therapists with whom they work
Clinical director will audit random chart monthly to ensure documentation of release of information for insurance providers |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment in one of one applicable client record reviewed.
Client #12 was admitted on February 26, 2024 and was involuntarily terminated on April 1, 2024. There was no documentation in the record indicating the client received written notification of the termination.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff has been notified of regulation regarding involuntary termination of services and need to be notified in writing indicating the reason for termination.
Clinical director will notify clients terminated involuntarily of decision to terminate and document this notification in electronic record moving forward.
Clinical director will review involuntary discharges monthly to ensure notification was provided in writing. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to ensure a client was given an opportunity to request reconsideration of a decision terminating treatment in one of one applicable client record reviewed.
Client #12 was admitted on February 26, 2024 and was involuntarily terminated on April 1, 2024. There was no documentation in the record indicating the client was given any opportunity to request reconsideration of the involuntary termination.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical director will include in written notification of discharge and reason that individuals can request reconsideration related to decision to terminate services in writing when involuntarily discharged from services. This notification will documented in electronic record.
Clinical director will review involuntary discharges monthly to ensure notification was provided in writing. |
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 a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in two of two applicable client records reviewed.
Client #10 was admitted into the partial hospitalization level of care on July 30, 2024 and was active at the time of inspection. The comprehensive treatment plan was completed on August 6, 2024 and the first update was due no later than September 6, 2024; however, the update was not completed at the time of the inspection.
Client #14 was admitted into the partial hospitalization level of care on February 7, 2024 and was discharged on March 25, 2024. The comprehensive treatment plan was completed on February 12, 2024 and the first update was due no later than March 12, 2024; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff was notified and will continue to be monitored by Clinical Director related to ensuring treatment plans are updated at least every 30 days at 2.5 level of care.
Clinical director will audit random chart monthly and asses for timely completion of treatment plan updates.
Client #10's treatment plan was updated on 9/12/2024.
Client #14 was discharged from services on 3/25/24, and as such updating treatment plan was not completed |
709.83(a)(11) LICENSURE Client records
709.83. 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 maintain a complete client record, which is to include the documentation of follow-up information, in three of four applicable client records reviewed.
Client #12 was admitted into the partial hospitalization level of care on February 26, 2024 and was discharged on April 1, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client #13 was admitted into the partial hospitalization level of care on March 21, 2024 and was discharged on April 22, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client #14 was admitted into the partial hospitalization level of care on February 7, 2024 and was discharged on March 25, 2024. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Business Development will be responsible for completing and documenting follow up calls for discharged clients moving forward.
Clinical Director and Director of Business Development will review discharges and follow up calls completed/required monthly to ensure compliance. |
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 treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of four applicable client records reviewed.
Client #1 was admitted into the outpatient level of care on September 11, 2023 and was still active at the time of inspection. A treatment plan update was completed on April 30, 2024 and the next update was due no later than June 30, 2024; however, the update was not completed until September 9, 2024.
Client #2 was admitted into the outpatient level of care on July 9, 2024 and was still active at the time of inspection. The comprehensive treatment plan was completed on July 9, 2024 and the first update was due no later than September 9, 2024; however, the update was not completed as of the date of the inspection.
Client #4 was admitted into the outpatient level of care on March 25, 2024 and was discharged on May 28, 2024. The comprehensive treatment plan was completed on March 25, 2024 and the first update was due no later than May 25, 2024; however, the update was not completed prior to discharge.
Client #5 was admitted into the outpatient level of care on June 26, 2024 and was discharged on August 30, 2024. The comprehensive treatment plan was completed on June 26, 2024 and the first update was due no later than August 26, 2024; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff was notified and will continue to be monitored by Clinical Director related to ensuring treatment plans are updated at least every 30 days at 2.5 level of care.
Clinical director will audit random chart monthly and asses for timely completion of treatment plan updates.
Client #1's treatment plan was updated on 9/9/24. Next update will be completed no later than 11/8/24
Client #2 was discharged from services as of 9/18/24, treatment plan unable to be updated at this time
Client #4 had been discharged on 05/24, treatment plan unable to be updated at this time
Client #5 was discharged on 08/30/24, treatment plan unable to be updated at this time |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of aftercare plans, if applicable, in two of two applicable client records reviewed.
Client #5 was admitted into the outpatient level of care on June 26, 2024 and was discharged on August 30, 2024. There was no aftercare plan documented in the record at the time of the inspection.
Client #6 was admitted into the outpatient level of care on June 5, 2024 and was discharged on August 23, 2024. There was no aftercare plan documented in the record 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 staff informed to complete aftercare plans prior to discharge when applicable.
Clinical Director will review discharged clients to ensure compliance with documentation of aftercare planning.
Unable to correct documentation for clients #5 and #6 as they have been discharged from services. |
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 maintain a complete client record, which is to include the documentation of follow-up information, in two of two applicable client records reviewed.
Client #4 was admitted into the outpatient level of care on March 25, 2024 and was discharged on May 28, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client #7 was admitted into the outpatient level of care on March 18, 2024 and was discharged on June 25, 2024. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Business Development will be responsible for completing and documenting follow up calls for discharged clients moving forward.
Clinical Director and Director of Business Development will review discharges and follow up calls completed/required monthly to ensure compliance. |