INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10, 2023 and February 13, 2023 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on February 10, 2023, the facility failed to ensure that exits from rooms and from the nonresidential facility were unobstructed as the door connecting the group room to the second exit was obstructed as it was locked.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A signage with the words "Emergency Egress Only" was posted at this particular door on the same day of this discovery. Facility Director performs weekly inspection to ensure this door is not blocked nor locked for egress purpose. A picture of the signage was sent to DDAP inspector on 2/21/23. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on February 10, 2023, the facility failed to light interior exits and stairs at all times as an emergency exit on the side of the facility led through an unlit stairwell.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We submitted a maintenance service request on 2/18/23 to our landlord to replace light bulbs of overhead pendant lighting in the north egress route of the building.
On 3/28/23, the building landlord informed that the light was replaced with a photocell, therefore the light will illuminate as the surrounding area gets darker.
The Facility Director will add the lighting inspection as part of our monthly fire drill including our egress route and document any issues encountered during the fire drill.
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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 the project ' s policy manual and discussion with staff, the facility failed to ensure that the written procedures for the management of treatment/rehabilitation services included timeframes for when documentation related to the completion of progress notes was to be completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director reviews the Treatment/Rehabilitation Services policy and agrees to include an additional time requirement for when the completion of progress notes are to be completed. The expectation will be within 72 hours after each service is rendered. Facility Director conducted documentation training on 3/15/23 with all clinical staff about this new requirement to the policy which will be effective starting 3/15/2023.
Facility Director/Supervisor will perform a random monthly audit to ensure progress notes are completed within 72 hours after each service is rendered.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of thirteen records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in one record reviewed.
Client #13 was admitted to the Outpatient Level of care on August 24, 2022 and was active at the time of the inspection. The record contained a consent to release information form to a treatment provider signed by the client on August 26, 2022, that was missing the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is committed to ensuring that consents to release information forms completed by clients include the specific information to be disclosed.
Client #13 selected the option of "Other" and handwrote "communicate regarding treatment" as information to be disclosed to an outside provider.
The Facility Director provided training with administrative and clinical staff on 3/15/23, specifically addressing the proper completion of the release forms, including the specific information to be disclosed.
The Facility Director will conduct monthly random audits to ensure compliance. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on interviews with facility staff, a review of the facility ' s policy manual and a review of client records, the facility failed to ensure consent to release information forms included the purpose of disclosure in eight client records reviewed.
During the February 9, 2023, licensing inspection at the Providence Living LLC facility located in Philadelphia, the Licensing Specialist informed facility staff that their consent to release information form to funding sources did not include a purpose of disclosure.
Providence Living LLC staff acknowledged their agency-wide consent to release information form to funding sources does not include a purpose of disclosure. However, a day later during the licensing inspection at the Providence Living LLC facility located in Media, the "purpose of disclosure" was handwritten on consent to release of information forms to funding sources in eight client records. Staff at Providence Living LLC could not explain who modified the release forms or when the release forms were modified. Additionally, they confirmed it was not their policy to handwrite "purpose of disclosure" on release forms.
Client #1 was admitted to the Partial level of care on January 3, 2023 and was active at the time of the inspection. The modified consent to release information form to the funding source was dated November 28, 2022.
Client #2 was admitted to the Partial level of care on January 18, 2023 and was active at the time of the inspection. The modified consent to release information form to the funding source was dated December 17, 2022.
Client #4 was admitted to the Partial level of care on November 14, 2022 and was discharged on December 12, 2022. The modified consent to release information form to the funding source was dated November 11, 2022.
Client #5 was admitted to the Partial level of care on July 22, 2022 and was discharged on August 24, 2022. The modified consent to release information form to the funding source was dated July 27, 2022.
Client #6 was admitted to the Partial level of care on May 16, 2022 and was discharged on June 8, 2022. The modified consent to release information form to the funding source was dated April 6, 2022, which was prior to admission.
Client #7 was admitted to the Partial level of care on August 1, 2022 and was discharged on August 31, 2022. The modified consent to release information form to the funding source was dated August 1, 2022.
Client #11 was admitted to the Outpatient level of care on November 28, 2022 and was active at the time of the inspection. The modified consent to release information form to the funding source was dated November 28, 2022.
Client #12 was admitted to the Outpatient level of care on April 8, 2022 and was active at the time of the inspection. The modified consent to release information form to the funding source was dated April 8, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director reviews the confidentiality policy and commits to the accuracy of the release of information from our clients. The consent of release information form was revised and implemented on 3/15/23 to include purpose of the disclosure, particularly related to the funding source, which will eliminate the staff's handwriting option and any other staff confusion.
Facility Director provided training to staff member by
3/15/2023 about the updated consent to release information form that includes the purpose of the disclosure to the funding source. This updated form becomes effective on 4/1/2023 and resend to our active clients for signature.
Facility Director/Supervisor will perform a random monthly audit to ensure the purpose of disclosure to the funding sources/insurers is listed and checked on the ROIs when the ROI is intended for their insurance payor.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of eight client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in three records reviewed.
Client #2 was admitted to the Partial level of care on January 18, 2023 and was active at the time of the inspection. The consent to release information form to the funding source was dated December 17, 2022; however, the facility was not open that day, so the actual date the form was signed could not be determined.
Client #6 was admitted to the Partial level of care on May 31, 2022 and was discharged on June 8, 2022. The consent to release information form to the funding source was dated April 6, 2022, which was prior to the client ' s admission.
Client #12 was admitted to the Outpatient level of care on April 8, 2022 and was active at the time of the inspection. The consent to release information form to the funding source had " whiteout " correction fluid over the original date it was signed. The actual date the form was signed could not be determined.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure the completion of all consents for the disclosure of information including the signature of the client and the date the form was completed. The Facility Director provided training with the administrative staff on 3/30/23 about the proper way to complete a release of information (ROI) that includes all signatures and dates. The training also included the proper method to strikethrough the info when mistakes are found, not using correction fluid.
The Facility Director will request client #2, #6 and #12 to re-sign our treatment consent form and the newly revised release form by 4/21/23.
The Facility Director will conduct random monthly audits of ROIs to ensure full compliance. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an onsite licensing inspection, the facility failed to develop a data collection and recordkeeping system that allowed for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives. A complete list of discharged clients since the last licensing inspection was requested and it took over two hours before it was produced.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has the data readily available on all active and discharged clients since last DDAP inspection. We regretted the delay of providing the list of discharged clients to the inspector as we were distracted by our daily operational issues at our facility on the day of the inspection.
Facility Director will continue to perform a monthly random audit of our recordkeeping system to ensure that the data of all active and discharged clients is made available for next DDAP inspection. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. 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 facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in seven of seven records reviewed.
Client #1 was admitted to the Partial level of care on January 3, 2023 and was active at the time of the inspection. The treatment plan completed on January 4, 2023, indicated that the client was to receive 18 hours of group per week; however, the record only contained documentation of 13 group session hours during the week of January 8, 2023.
Client #2 was admitted to the Partial level of care on January 18, 2023 and was active at the time of the inspection. The treatment plan completed on January 20, 2023, indicated that the client was to receive 18 hours of group per week; however, the record only contained documentation of 16 group session hours the week of January 22, 2023.
Client #3 was admitted to the Partial level of care on January 23, 2023 and was active at the time of the inspection. The treatment plan completed on January 23, 2023, indicated that the client was to receive 18 hours of group per week; however, the record only contained documentation of 14 group session hours the week of January 30, 2023.
Client #4 was admitted to the Partial level of care on November 14, 2022 and discharged on December 12, 2022. The treatment plan completed on November 11, 2022, indicated that the client was to receive 20 hours of group and two hours of individual sessions per week; however, the record only contained documentation of 16 group session hours and one individual session the week of November 14, 2022.
Client #5 was admitted to the Partial level of care on July 27, 2022 and discharged on August 24, 2022. The treatment plan completed on August 3, 2022, indicated that the client was to receive 18 hours of group sessions per week; however, the record only contained documentation of 16 group session hours the week of August 8, 2022.
Client #6 was admitted to the Partial level of care on May 16, 2022 and was discharged on June 8, 2022. The treatment plan completed on May 17, 2022, indicated that the client was to receive 20 hours of group sessions per week; however, the record only contained documentation of 17 group session hours the week of May 23, 2022.
Client #7 was admitted to the Partial level of care on August 1, 2022 and was discharged on August 31, 2022. The treatment plans completed on August 1, 2022 and August 16, 2022, indicated that the client was to receive 18 hours of group sessions per week; however, the record only contained documentation of 16 group session hours the weeks of August 8, 2022 and August 15, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that counseling services are provided according to the client's individual treatment plan. The Facility Director provided documentation training with all clinical staff on 3/30/23 about proper documentation of all scheduled therapeutic sessions to be completed according to individual treatment plan. The Facility Director will address any issues related to documentation of treatment sessions in supervision sessions with clinicians.
The Facility Director is responsible for monthly audits of client charts to ensure compliance. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes in two of three applicable client records reviewed.
Client #4 was admitted to the Partial level of care on November 14, 2022 and discharged on December 12, 2022. There was no documentation of a case consultation in the record.
Client #5 was admitted to the Partial level of care on July 27, 2022 and discharged on August 24, 2022. There was no documentation of a case consultation in the record.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that case consultation documentation is completed on all active clients and placed in the client's chart. The Facility Director will provide training on 4/14/23 to ensure that all staff are aware of the new policy pertaining to case consultations, which included: The first case consultation is completed on each client within the first (30) days. Subsequent case consultation will be conducted on an as-needed basis.
The Facility Director will conduct a monthly audit of all admitted clients within the past month and all future clients to ensure compliance. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of six client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 3 weeks of admission, per their policy, in two records.
Client #9 was admitted on June 8, 2022 and discharged on August 18, 2022. The individual treatment and rehabilitation plan was not signed as completed until February 7, 2023.
Client #12 was admitted on April 8, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan was not signed as completed until May 25, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will ensure that an individual Master treatment and rehabilitation plan is completed and developed with the client within three (3) weeks of admission. The Facility Director will conduct training on 4/14/23 with clinicians on the completion of individual treatment and rehabilitation plans, both Master and updated plans with client involvement in the treatment plan.
The Facility Director will ensure compliance with a monthly audit of all new admissions in the past month and all future clients. |
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 three of five applicable client records reviewed.
Client #10 was admitted to the outpatient level of care on August 29, 2022 and was discharged on November 7, 2022. The comprehensive treatment plan was completed on August 29, 2022, and the first treatment plan update was due no later than October 29, 2022; however, the finalized treatment plan update was signed and dated by the counselor on February 7, 2023.
Client #12 was admitted to the outpatient level of care on April 8, 2022 and was active at the time of inspection. A treatment plan update was completed on October 31, 2022, and the next update was due no later the December 31, 2022; however, the finalized treatment plan update was signed and dated by the counselor until January 11, 2022.
Client #13 was admitted to the outpatient level of care on August 24, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on August 24, 2022, and the first treatment plan update was due no later than October 24, 2022; however, the finalized treatment plan update was signed and dated by the counselor until November 3, 2022. Additionally, a treatment plan update was completed on November 15, 2022, and the next update was due no later than January 15, 2023; however, the finalized treatment plan update was signed and dated by the counselor until January 23, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director shall ensure that all treatment and rehabilitation plans are reviewed and updated every sixty (60) days. The Facility Director will conduct training on 4/14/23 on how to complete an updated treatment plan. The Facility Director will conduct a monthly audit to ensure compliance of the treatment plan updates. |
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 facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of six applicable records reviewed.
Client #8 was admitted to the outpatient level of care on December 12, 2022 and was discharged on January 23, 2023. The treatment plan completed on January 9, 2023, indicated that the client was to receive 9 hours of group per week; however, the record only contained documentation of 8 group session hours during the week of January 9, 2023.
Client #10 was admitted to the outpatient level of care on August 29, 2022 and was discharged on November 7, 2022. The treatment plan completed on August 29, 2022, indicated that the client was to receive 8 hours of group per week; however, the record only contained documentation of 5 group session hours the week of September 5, 2022.
Client #11 was admitted to the outpatient level of care on November 28, 2022 and was active at the time of the inspection. The treatment plans completed on November 28, 2022 and December 8, 2022, indicated that the client was to receive 8 hours of group sessions per week; however, the record only contained documentation of 5 group session hours the week of December 5, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that all counseling services are provided documented in accordance with the frequency on the client's treatment plan. The Facility Director will address any documentation issues in supervision sessions with clinicians. The Facility Director will conduct a training on documentation on 4/14/23 with all clinical staff members.
The Facility Director will conduct monthly audits to ensure compliance of proper documentation of all counseling services. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes in two of four applicable client records reviewed.
Client #8 was admitted to the outpatient level of care on December 12, 2022 and discharged on January 23, 2023. There was no documentation of a case consultation in the record.
Client #9 was admitted to the outpatient level of care on June 8, 2022 and discharged on August 18, 2022. There was no documentation of a case consultation in the record.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that case consultation documentation is completed on all active clients and placed in the client's chart. The Facility Director will provide training on 4/14/23 to ensure that all staff are aware of the new policy pertaining to case consultations, which included: The first case consultation is completed on each client within the first (30) days. Subsequent case consultation will be conducted on an as-needed basis.
The Facility Director will conduct a monthly audit of all admitted clients within the past month and all future clients to ensure compliance. |