INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 29, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure the supervised period of a counselor assistant, with a high school diploma or GED equivalent, included the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment and close supervision for the following 9 months in one of one applicable personnel record reviewed.Close supervision is defined as formal documented case review and an additional hour of direct observation by a supervising counselor or clinical supervisor once a week.Employee #3 was hired as a counselor assistant on April 3, 2023. There was no documentation in the personnel record in which the employee received direct observation once a week from July, 2023 through the date of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Although Clinical Director has regularly observed groups and individual sessions facilitated by Employee #3, this has not been documented as such. Effective immediately, Project Director will ensure that close and direct supervision are performed and documented by a monthly review of supervision documentation. Policies and Procedures will be updated to reflect this as well. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that each written individual training plan was based upon an employee's previous education, experience, current job functions, and performance in three of three personnel records reviewed.In each personnel record reviewed, the individual training plans were identical. The plans were not individualized based upon each specific employee's previous education, experience, current job functions and job performance. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will develop individualized training plans for all staff, as part of their annual performance review and goals for the coming year. Policies and Procedures have been updated to reflect the importance of individualizing treatment plans for all staff. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed as there was a space heater located in the project director's office. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The space heater has been removed from the facility as of 3/1/24. Safety Committee will complete monthly facility inspections to ensure that all equipment meets all safety requirements, in accordance with 28 Pa Code 705.26(2). |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the April 2023 through January 2024 fire drill logs, the facility failed to identify, on their drill log, which exit route was used for the fire drill conducted in January 2024.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Safety Committee will perform monthly reviews of fire drill logs to ensure that all procedures are followed correctly and in accordance with 28 Pa Code 705.28(d)(4). |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that an annual written individual performance evaluation, which is to be reviewed and signed by the employee, was completed in one of one applicable personnel record reviewed.Employee #1 was hired as the project director on January 14, 2024; however, the employee was also in a clinical position at this facility since December 13, 2022. There was no documentation, in the personnel record, of an annual written individual performance evaluation for the 2023 reviewed year.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the abrupt departure of the Chief Clinical Officer, an annual performance review was not completed by the time of the inspection. A review has been completed by the Chief Operating Officer, and will be completed annually. |
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 follow up information, in two of four applicable client records reviewed.Client #3 was admitted October 9, 2023 and was discharged on January 25, 2024. There was no follow-up information documented in the record at the time of the inspection.Client #4 was admitted December 8, 2023 and was January 15, 2024. There was no follow-up information documented in the record at the time of the inspection.This is a repeat citation from the March 28, 2023 annual licensing renewal inspection and the August 8, 2023 provisional license follow-up inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #3 was discharged 34 days prior to the inspection being conducted; and therefore was 4 days past due for their 30 day follow up. Client #4 was discharged 44 days prior to the inspection being conducted; and was therefore 14 days past due for their 30 day follow up. In reviewing this with staff, we have developed a system that will better ensure that follow-up contact is being made in a more timely manner.
Project director has developed a spreadsheet with all clients as they discharge; this spreadsheet will alert staff when clients are due for follow up contact. This will be reviewed during weekly staff meetings to ensure timely contact of alumni.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on an administrative review, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for documenting follow-up information in the client record was submitted and approved by the Department for the March 28, 2023 annual licensing renewal inspection and the August 8, 2023 provisional license follow-up inspection. Not documenting follow-up information was again found to be a deficiency in the February 29, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
While we recognize that this is a repeat citation, we submit that the majority of follow-up was completed with discharged clients, and that the two client charts that were observed to have been out of compliance were very recent discharges, and their follow-ups were only just past due.
Project director has developed a spreadsheet with all clients as they discharge; this spreadsheet will alert staff when clients are due for follow up contact. This will be reviewed during weekly staff meetings to ensure timely contact of alumni.
Project Director will build a Quality Assurance Committee; the goal of this committee is to review Policies and Procedures to ensure that they are in alignment with 28 Pa Code, and to ensure that Policies and Procedures are followed appropriately. The committee will also review approved Plans of Correction to ensure that procedures are followed consistently.
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