INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 18, 2024, 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 dba 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(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 seven personnel records, the facility failed to provide a written individual training plan for each employee, that documented it was developed annually with input from both the employee and the supervisor in seven personnel records reviewed.
Employee # 1 has been in the position of Project Director since June 25, 2015. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee # 2 was hired as the Facility Director on November 7, 2023. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee # 3 was hired as a counselor on November 9, 2020. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee # 4 was hired as a counselor on July 17, 2023. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee # 5 was hired as a counselor on April 24, 2023. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee # 6 was hired as a counselor on July 28, 2022. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee # 7 was hired as a counselor on November 13, 2023. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director updated the staff development policy to require each employee to sign the individual training plan with wet signature and the electronic signature will no longer be permitted.
The practice will further confirm that a meeting is taken place to discuss their individual training plan between the employee and the supervisor.
The Program Director will perform an annual audit on all completed individual training plan to ensure compliance. |
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 five records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in one record reviewed.
Client # 4 was admitted to the Outpatient level of care on December 4, 2023 and was active at the time of the inspection. The record contained consent to release information forms to a family member signed by the client on November 29, 2023 and December 6, 2023, that were missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director conducted a staff training with all the administrative support staff about the confidentiality policy for the consent to release information forms, particularly on specific information to be disclosed.
Client #4 was contacted and the consent for specific information to be disclosed was clarified and corrected on the form.
The Facility Director will perform a random monthly audit on completed consent to release information forms to ensure compliance. |
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 one of one applicable client record reviewed.
Client # 5 was admitted to the Outpatient level of care on September 27, 2023 and was discharged on January 2, 2024. The comprehensive treatment plan was completed on October 11, 2023, and the first treatment plan update was due no later than December 11, 2023; however, the finalized treatment plan update was not entered until January 17, 2024.
These findings were reviewed with facility 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 2/9/24. 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 60 days for clients who are in the OP level of care.
The Facility Director will perform a monthly audit to ensure the treatment plan is reviewed and updated every 60 days in OP level of care. |
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 five records reviewed.
Client # 2 was admitted on November 20, 2023 and was discharged December 8, 2023. The record contained progress notes for group sessions occurring on November 27, 2023 and December 4, 2023, that were not completed until December 29, 2023 and December 10, 2023 respectively. Additionally, the record contained a progress note for an individual session occurring on November 28, 2023, that was not completed until December 19, 2023.
Client # 3 was admitted on November 16, 2023 and was active at the time of the inspection. The record contained progress notes for group sessions occurring on December 4, 2023 and January 11, 2024, that were not completed until December 10, 2023 and January 17, 2024, respectively.
Client # 5 was admitted on September 27, 2023 and was discharged on January 2, 2024. The record contained progress notes for group sessions occurring on November 20, 2023 and November 29, 2023, that were not completed until December 6, 2023 and December 5, 2023, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director conducted a staff training on 2/9/24 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 perform a weekly audit to ensure all progress notes are completed within the required timeline. |
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 the facility policy and procedure manual, the policy for case consultation notes indicated that the primary therapist assigned to the client would be in attendance. Two of four applicable records reviewed did not include the primary therapist ' s participation in the case consultation.
Client # 3 was admitted on November 16, 2023 and was active at the time of the inspection. The case consultation note on December 8, 2023 did not contain documentation of that the primary therapist participated.
Client # 4 was admitted on December 4, 2023 and was active at the time of the inspection. The case consultation note on December 22, 2023 did not contain documentation of that the primary therapist participated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director conducted a staff training about client records policies to all clinical staff members on 2/9/24. The training discussed on the participation of the primary therapist in the team meeting. When the primary therapist is not available, the Facility Director will reschedule the case consultation to the next team meeting when the primary therapist is available.
The Facility Director will perform a monthly audit to ensure primary therapist is in attendance and participates in the team meeting for case consultation discussion. |
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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information at 14-days post discharge, per facility policy, in one of two applicable records reviewed.
Client # 2 was admitted on November 20, 2023 and was discharged December 8, 2023. The follow-up information was not completed until January 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director conducted a staff training on 2/9/24 and reviewed the client records policy with all administrative support staff about the client's follow up at 14 days post discharge.
The Facility Director will perform a monthly audit to ensure compliance. |