INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2022 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the regulatory timeframe for the position in one of seven personnel records reviewed.
Employee # 7 was hired as the Practice Manager on January 14, 2020 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than January 14, 2022; however, there was no documentation of completion of the HIV/AIDS training and the TB/STD training at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #7 is scheduled to complete her required HIV/AIDS and TB/STD trainings by April 15, 2022.
All support staff (non clinicians) will be instructed of their training requirements (HIV/AIDS and TB/STD) at the time of hire and their first annual performance review. This shall be documented by the Facility Director in the staff person's file as of 5/1/2022. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in five of fourteen client records reviewed.
Client #2 was admitted to the partial hospitalization level of care on November 8, 2021 and was discharged on December 20, 2021. The written procedure manual stated that the comprehensive treatment plan will be completed within 14 days of admission. The comprehensive treatment plan was due no later than November 22, 2021; however, the plan was completed by the counselor on December 8, 2021.
Client #8 was admitted to the outpatient level of care on May 7, 2021 and was discharged on December 18, 2021. The written procedure manual stated that follow-up information will be completed within 7 days of discharge. The follow-up information was due no later than December 25, 2021; however, follow-up was completed on December 27, 2021.
Client #11 was admitted to the outpatient level of care on July 5, 2021 and was discharged on September 29, 2021. The written procedure manual stated that aftercare plan will begin at admission and be reviewed with the client throughout treatment. The aftercare plan was completed post-discharge and signed by the counselor on December 1, 2021.
Client #12 was admitted to the outpatient level of care on April 5, 2021 and was active at the time of inspection. The written procedure manual stated that case consultation notes will be completed at least every 90 days. A case consultation was completed on April 21, 2021, and the next case consultation was due no later than July 21, 2021; however, the consultation was not completed as of the date of the inspection.
Client #13 was admitted to the outpatient level of care on May 24, 2021 and was active at the time of inspection. The written procedure manual stated that case consultation notes will be completed at least every 90 days. A case consultation was completed on July 2, 2021, and the next case consultation was due no later than October 2, 2021; however, the consultation was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2. In regards to their comprehensive treatment plan, please see revised policy and procedure for treatment planning.
Client #8 & #11. In regards to discharge follow-up, please see revised policy and procedure for aftercare planning and discharge follow-up.
Clients #12 and #13. In regards to case consultations, please see revised policy and procedure for case consultations.
Facility Director will provide treatment planning, case consultation, aftercare planning and post treatment follow up training on 4/1/22 to all clinical staff. This will include all current and revised policies and procedures regarding aftercare planning. Facility Director will conduct a quarterly audit with all discharged clients within the quarter.
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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 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.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An audit of our financials for 2020-2021 will be conducted and a CPA audit report shall completed by May 31, 2022. This will include an opinion by the Certified Public Accountant (CPA) that the facility's financial statements, the financial position and the results of the operations of the organization presents fairly.
Going forward the COO will be responsible to ensure compliance with an annual audit, completed by the CPA, each year by May 31st. |
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 facility failed to obtain a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in six of fourteen client records reviewed.
Client #1 was admitted to the partial hospitalization level of care on April 16, 2021 and was discharged on May 7, 2021. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #3 was admitted to the partial hospitalization level of care on November 16, 2021 and was discharged on December 20, 2021. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #5 was admitted to the partial hospitalization level of care on April 30, 2021 and was discharged on May 24, 2021. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #8 was admitted to the outpatient level of care on May 7, 2021 and was discharged on December 18, 2021. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #10 was admitted to the outpatient level of care on December 20, 2021 and was discharged on February 10, 2022. A release of information form to the funding source was signed and dated by the client on January 6, 2022; however, there was documentation of disclosures to the funding source between December 20, 2021 and January 5, 2022, prior to the client signing the release form.
Client #13 was admitted to the outpatient level of care on May 24, 2021 and was active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1, #3, #5, #8, #10, and #13. In regards to disclosures of information to funding sources, we revised our policy and procedure to reflect the ROI to expire sixty (60) days post-discharge. The Facility Director will conduct training for all staff members on this topic on 4/8/22. Practice Manager will implement the revised ROI form starting 4/11/2022. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of fourteen client records reviewed.
Client #14 was admitted to the outpatient level of care on August 30, 2021 and was active at the time of inspection. A release of information form was signed and dated by the client and witness on August 6, 2021; however, the name of the person, agency, or organization to whom disclosure was to be made was not documented on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #14. Release for information form was updated on 2/24/22. The Facility Director will conduct training on Release for Information topic on 4/8/22. Practice Manager will conduct quarterly audit to ensure completeness of Release for information form. |
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 a review of client records, the facility failed to ensure that clients admitted to the partial hospitalization program received individual counseling services at least twice weekly in three of seven applicable client records reviewed.
Client #1 was admitted on April 16, 2021 and was discharged on May 7, 2021. There was one documented individual counseling session that occurred on April 22, 2021 for the week of April 18, 2021 - April 24, 2021. Additionally, there was one documented individual counseling session that occurred on April 29, 2021 for the week of April 25, 2021 through May 1, 2021.
Client #5 was admitted on April 30, 2021 and was discharged on May 24, 2021. There was no documentation of individual counseling sessions occurring during the week of May 2, 2021 through May 8, 2021.
Client #7 was admitted to the partial hospitalization level of care on February 7, 2022 and was active at the time of inspection. There was one documented individual counseling session that occurred on February 16, 2022 for the week of February 13, 2022 through February 19, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1, #5 and #7. Regarding individual sessions for clients in partial hospitalization programming, the Facility Director will train clinical staff on the frequency of individual sessions during partial hospitalization programming on 4/1/22. Office Manager will perform a weekly audit to ensure that clients in partial programming receive two (2) individual sessions per week. This audit will be signed off by the Supervisor/Facility Director. |
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 that treatment and rehabilitation plans are reviewed and updated at least every sixty days in four of seven applicable client records reviewed.
Client #8 was admitted to the outpatient level of care on May 7, 2021 and was discharged on December 18, 2021. The comprehensive treatment plan was completed on May 18, 2021, and the first treatment plan update was due no later than July 18, 2021; however, the finalized treatment plan update was signed and dated by the counselor on September 13, 2021.
Client #12 was admitted to the outpatient level of care on April 5, 2021 and was active at the time of inspection. A treatment plan update was completed on June 4, 2021, and the next update was due no later the August 4, 2021; however, the finalized treatment plan was signed and dated by the counselor on August 9, 2021. Additionally, a treatment plan update was completed on October 1, 2021, and the next update was due no later than December 1, 2021; however, the finalized treatment plan update was signed and dated by the counselor on December 9, 2021.
Client #13 was admitted to the outpatient level of care on May 24, 2021 and was active at the time of inspection. A treatment plan update was completed on November 3, 2021, and the next update was due no later than January 3, 2022; however, the finalized treatment plan update was signed and dated by the counselor on January 19, 2022.
Client #14 was admitted to the outpatient level of care on August 30, 2021 and was active at the time of inspection. A treatment plan update was completed on October 23, 2021, and the next update was due no later than December 23, 2021; however, the finalized treatment plan update was signed and dated by the counselor on January 4, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #8, #12, #13 and #14. Regarding treatment plan updates, the Facility Director will provide training on treatment planning that includes review and update timelines on April 8, 2022. The Facility Director will conduct a quarterly audit on treatment planning and updates. Any cases not in compliance shall be documented in a performance supervision session with the clinician. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on an administrative review, the facility failed to notify the Department, within 90 days, of a change in the authorized maximum capacity. The facility is licensed for the Outpatient activity with a maximum capacity of 45. Based on the Staffing Requirements Facility Summary Report, submitted by the facility on February 23, 2022, the facility had 51 active clients in the Outpatient activity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In regards to the notification to the Department about any increase of maximum capacity, the Facility Director will monitor client census and maximum capacity quarterly and report to DDAP any changes in capacity. Request for change in facility capacity will be submitted to DDAP on 3/28/2022. |