INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3 and March 5, 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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709.82(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 #8 was admitted on April 11, 2024 and was discharged on June 20, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on May 7, 2024, and the update was due no later than June 7, 2024; however, the treatment plan update was not documented in the record until June 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 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 eight partial hospitalization clients reviewed.
Client #4 was admitted on April 19, 2024 and was discharged on July 9, 2024. The project only documented one individual counseling session for the weeks of May 19, 2024 through May 25, 2024, June 2, 2024 through June 8, 2024, June 9, 2024 through June 15, 2024, June 16, 2024 through June 22, 2024 and June 30, 2024 through July 16, 2024. Additionally, the project did not document any individual counseling session for the weeks of May 26, 2024 through June 1, 2024 and June 23, 2024 through June 29, 2024.
Client #6 was admitted on June 3, 2024 and was discharged June 20, 2024. The project did not document any individual counseling sessions for the week of June 9, 2024 through June 15, 2024.
Client #7 was admitted on October 28, 2024 and was discharged on November 25, 2024. The project only documented one individual counseling session for the weeks of November 10, 2024 through November 16, 2024 and November 17, 2024 through November 23, 2024. Additionally, the project did not document any individual counseling session for the week of November 3, 2024 through November 9, 2024.
Client #8 was admitted on April 11, 2024 and was discharged on June 20, 2024. The project only documented one individual counseling session for the weeks of April 14, 2024 through April 20, 2024 and June 9, 2024 through June 15, 2024. Additionally, the project did not document any individual counseling session for the weeks of May 5, 2024 through May 11, 2024, May 26, 2024 through June 1, 2024 and June 2, 2024 through June 8, 2024.
This is a repeat citation from the January 12, 2024, annual licensing renewal inspection.
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, be it excused or unexcused absence, 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. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within four days of the date of service, per the facility's policy, in five of eight records reviewed.
Client #3 was admitted on January 20, 2025 and was a current client at the time of the inspection. The record contained progress notes for an individual counseling session and a group counseling session, both occurring on February 14, 2025, that were not documented in the record until February 24, 2025. Additionally, the record contained a progress note for a group counseling session occurring on February 17, 2025 that was not documented in the record until March 2, 2025.
Client #4 was admitted on April 19, 2024 and was discharged on July 9, 2024. The record contained progress notes for individual counseling sessions occurring on May 8, 2024 and May 9, 2024 that were not documented in the record until June 3, 2024 and June 20, 2024.
Client #5 was admitted on July 8, 2024 and was discharged on July 22, 2024. The record contained missed session progress notes that were to occur on July 11, 2024 and July 19, 2024 that were not documented in the record until August 9, 2024. Additionally, a termination of treatment progress note that occurred on July 22, 2024 was not documented in the record until January 3, 2025.
Client #7 was admitted on October 28, 2024 and was discharged on November 25, 2024. The record contained progress notes for three group counseling session occurring on November 7, 2024 that were not documented in the record until November 15, 2024. Additionally, a termination of treatment progress note that occurred on January 10, 2025 was not documented in the record until February 25, 2025.
Client #8 was admitted on April 11, 2024 and was discharged on June 20, 2024. The record contained missed session progress notes that were to occur on April 15, 2024, April 22, 2024, April 24, 2024, May 6, 2024, May 9, 2024, May 22, 2024, May 28, 2024, June 4, 2024, June 12, 2024, June 19, 2024 and July 9, 2024, all of which were not documented in the record until February 19, 2025. Additionally, the record contained missed session progress notes that were to occur on July 15, 2024, July 22, 204 and July 25, 2024, all of which were not documented in the record until September 12, 2024.
This is a repeat citation from the January 12, 2024, annual licensing renewal inspection.
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 on
3/21/24 and reviewed the client records policy with all clinical staff members about the requirement of note completion within 4 days of the date of service.
The Facility Director will implement a new chart review process starting 4/14/25 and will perform a weekly audit to ensure all progress notes are completed within the required timeframe for all the clients in Partial Hospitalization level of care. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure that the intake procedures included documentation of a psychosocial evaluation within three weeks of admission in two of five applicable client records reviewed.
Client #11 was admitted on May 9, 2024 and was discharged on September 17, 2024. A psychosocial evaluation was to be documented in the client record by May 30, 2024; however, a psychosocial evaluation was not documented in the record until June 20, 2024.
Client #12 was admitted on March 11, 2024 and was an active client at the time of the inspection. A psychosocial evaluation was to be documented in the client record by April 1, 2024; however, there was no psychosocial evaluation documented in the record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The biopsychosocial evaluation for client #12 was completed on 3/29/24 and re-filed in the client's chart.
The Facility Director conducted a staff training with all clinical staff members on 3/21/25 about Care, Treatment and Service policy, focusing on the completion of biopsychosocial evaluation within three weeks of admission for all new clients.
The Facility Director will implement a new chart review process starting 4/14/25 and will perform a weekly audit of completed biopsychosocial evaluation for all newly admitted clients 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 five of seven applicable client records reviewed.
Client #11 was admitted on May 9, 2024 and was discharged on September 17, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on May 22, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of May 26, 2024 through June 1, 2024, June 23, 2024 through June 29, 2024, July 21, 2024 through July 27, 2024 and September 1, 2024 through September 7, 2024.
Client #12 was admitted on March 11, 2024 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on March 18, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of March 24, 2024 through March 30, 2024, March 31, 2024 through April 6, 2024, April 7, 2024 through April 13, 2024, May 26, 2024 through June 1, 2024, June 30, 2024 through July 6, 2024, September 1, 2024 through September 7, 2024 and September 15, 2024 through September 21, 2024.
Client #13 was admitted on April 19, 2024 and was an active client at the time of the inspection. An initial treatment and rehabilitation plan, documented in the client record on April 21, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of April 28, 2024 through May 4, 2024, May 5, 2024 through May 11, 2024, May 12, 2024 through May 18, 2024, May 19, 2024 through May 25, 2024, June 2, 2024 through June 8, 2024, June 16, 2024 through June 22, 2024, June 23, 2024 through June 29, 2024, June 30, 2024 through July 6, 2024, July 7, 2024 through July 13, 2024, July 14, 2024 through July 20, 2024, July 21, 2024 through July 27, 2024, September 1, 2024, through September 7, 2024, October 6, 2024 through October 12, 2024, October 13, 2024 through October 19, 2024, October 27, 2024 through November 2, 2024, November 10, 2024 through November 16, 2024, December 8, 2024 through December 14, 2024, December 22, 2024 through December 28, 2024, December 29, 2024 through January 4, 2025 and February 23, 2025 through March 1, 2025.
Client #14 was admitted on June 20, 2024 and was discharged on November 7, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on June 20, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of June 23, 2024 through June 29, 2024, June 30, 2024 through July 6, 2024, July 14, 2024 through July 20, 2024, September 15, 2024 through September 21, 2024 and October 20, 2024 through October 26, 2024.
Client #15 was admitted on June 20, 204 and was discharged on August 20, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on June 20, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of July 14, 2024 through July 20, 2024 and August 11, 2024 through August 17, 2024.
This is a repeat citation from the January 12, 2024, annual licensing renewal inspection.
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 and client records policies 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 documentation of such care being offered, even in the case when the client is not available to receive care. In addition, during the 3/21/25 staff training, the Project Director provided a refresher training about the use of our EMR software. Due to incorrect use of our EMR system resulted the missing documentation of the client's individual counseling session.
The Facility Director will implement a new chart review process on 4/14/25 and will perform a weekly random audit of progress notes to ensure the clients receive care according to their treatment plan as well as documentation of care delivery. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within four days of the date of service, per the facility's policy, in three of eight applicable records reviewed.
Client #11 was admitted on May 9, 2024 and was discharged on September 17, 2024. The record contained a missed session progress note that was to occur on July 15, 2024 that was not documented in the record until September 12, 2024.
Client #12 was admitted on March 11, 2024 and was an active client at the time of the inspection. The record contained progress notes for an individual counseling session, occurring on May 20, 2024, that was not documented in the record until June 12, 2024. Additionally, the record contained progress notes for a group counseling sessions, occurring on May 2, 2024, May 9, 2024 and January 3, 2025, that were not documented in the record until May 24, 2024, May 22, 2024 and January 13, 2025.
Client #16 was admitted on November 25, 2024 and was discharged on January 10, 2025. The record contained progress notes for group counseling sessions, occurring on November 1, 2024 and November 7, 2024, that were not documented in the record until November 13, 2024 and November 15, 2024. Additionally, the record contained a termination of treatment progress note, occurring on January 10, 2025, that was not documented in the record until February 25, 2025.
This is a repeat citation from the January 12, 2024, annual licensing renewal inspection.
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 on
3/21/25 and reviewed the client record policy with all clinical staff about the requirement of note completion within 4 days of the date of service.
The Facility Director will implement a new chart review process starting 4/14/25 and will perform a random weekly audit to ensure all progress notes are completed within the required timeline. |