INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to insure that there was sufficient on-site coverage of staff members' first aid training. The only staff person on-site had CPR certification, but failed to obtain first aid training. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The employee (#1) was scheduled for and completed first aid training on 2/18/19 to correct this finding.The training certification is now filed in the employee's personnel record.
Facility director will review each staff member's training needs on a monthly basis in order to ensure that requirements are continuing to be met. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in seven of seven client records reviewed. All seven records had a consent form to the client's funding source that allowed for the release of all clinical progress notes, treatment plans and all correspondence contained in the record. Client #1 was admitted January 22, 2019 and was active at the time of inspectionClient #2 was admitted February 11, 2019 and was active at the time of inspection. Client #3 was admitted June 28, 2018 and was discharged September 28, 2019.Client #4 was admitted September 28, 2018 and was discharged December 18. 2018.Client #5 was admitted July 31, 2018 and was discharged October 1, 2018.Client #6 was admitted August 28, 2018 and was discharged December 27, 2018.Client #7 was admitted July 19, 2018 and was discharged August 13, 2018.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Code 255.5 was reviewed with clinical staff in an all staff meeting on 02/20/2019. Specifically, the meeting focused on the information that may be disclosed by the agency with a signed release from the client. The information that may be disclosed with a signed release only includes:
-The client's presence in treatment.
-The nature of the project.
-A brief description of client's progress.
-Prognosis for client.
-Whether a client has relapsed and how frequently.
All clients with the exception of client #2 have been discharged from the program. Client #2's release to funding source has been changed to be in compliance with 4 Pa. Code 255.5 (b).
Charts will be reviewed monthly by the Project Director to ensure compliance.
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709.93(a) 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:
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Observations
The facility failed to provide a complete client record in five of seven records reviewed.Client #3 was admitted June 28, 2018 and was discharged September 28, 2019. The record failed to contain documentation of case consultation notes.Client #4 was admitted September 28, 2018 and was discharged December 18. 2018. The record failed to contain documentation of case consultation notes.Client #5 was admitted July 31, 2018 and was discharged October 1, 2018. The record failed to contain documentation of case consultation notes.Client #6 was admitted August 28, 2018 and was discharged December 27, 2018. The record failed to contain documentation of case consultation notes.Client #7 was admitted July 19, 2018 and was discharged August 13, 2018. The record failed to contain documentation of case consultation notes, an aftercare plan, a discharge summary and post-discharge follow-up information.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The case consultation form was reviewed with all clinical staff on 2/18/2019. Clinical staff were re-oriented to the form, its purpose, and its importance in addition to timeline for completion.
All charts moving forward immediately will include completed case consultation forms for each client per every 90 days of treatment.
The Facility Director will continue to conduct monthly chart reviews to ensure the completion of all necessary documentation in a timely manner. |