INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11, 2024 through January 12, 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 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(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 permitted.
The practice will further validate 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) 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 fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 13 was admitted to the Outpatient level of care on September 6, 2023 and was active at the time of the inspection. There was evidence of disclosures to two family members during a family counseling session on October 28, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #13 attended a scheduled and consenting family session. The client gave verbal consent and wished to engage his adult children as part of his treatment.
The Facility Director conducted a staff training to all clinical staff members on 2/9/24 about confidentiality and obtaining written consent from our clients when they wish to engage their loved ones in their treatment at Providence Treatment.
Going forward, the Facility Director will hold the primary therapists accountable to obtain consents to release information for each member attending a scheduled family session with a client.
The Facility Director will perform a random monthly audit of our client's chart 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 thirteen applicable records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in two records reviewed.
Client #2 was admitted to the Partial level of care on October 9, 2023 and was transferred to a lower level of care on November 21, 2023. The record contained a consent to release information form to a treatment provider signed by the client on September 25, 2023, that was missing the specific information to be disclosed.
Client # 11 was admitted to the Outpatient level of care on January 4, 2019 and was discharged on December 28, 2023. The record contained a consent to release information form to a treatment monitoring program signed by the client on October 4, 2023, that was 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 #2 and #11 were contacted and their respective consent to release of information forms were corrected properly.
The Facility Director will perform a random monthly audit on completed consent to release information forms to ensure their completeness. |
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 thirteen applicable client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in two records reviewed.
Client # 3 was admitted to the Partial level of care on July 28, 2023 and was transferred to a lower level of care on August 28, 2023. The consent to release information form to the funding source contained the client ' s electronic signature, but a date was not captured with the signature. Facility staff could not confirm that the form was actually signed on the date handwritten on the form after it was received from the client.
Client # 13 was admitted to the Outpatient level of care on September 6, 2023 and was active at the time of the inspection. The consent to release information form to the funding source contained the client ' s electronic signature, but a date was not captured with the signature. Facility staff could not confirm that the form was actually signed on the date handwritten on the form after it was received from the client.
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 requiring a client's signature with a date on the release form and documenting the client correspondence to show attempts to obtain the completed release form.
Release form for the funding source for Client #3 and #13 were corrected with proper signature and signed date.
The Facility Director will perform a random month audit on completed consent to release information forms to ensure compliance. |
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 seven records, the facility failed to ensure that counseling was provided to clients on a regular and scheduled basis, that included individual counseling, at least twice weekly in three records reviewed.
Client # 2 was admitted on October 9, 2023 and was transferred to a lower level of care on November 21, 2023. The record contained documentation of only one individual counseling session offered the weeks of November 6, 2023 and November 13, 2023.
Client # 3 was admitted on July 28, 2023 and was transferred to a lower level of care on August 28, 2023. The record contained documentation of only one individual counseling session offered the week of August 7, 2023.
Client # 4 was admitted on August 14, 2023 and was transferred to a lower level of care on September 6, 2023. The record contained documentation of only one individual counseling session offered the week of August 28, 2023.
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 care delivery and client records policies to all clinical staff members on 2/9/24. The training focused on the adherence of care delivery requirements according to the treatment plan at the Partial Hospitalization level of care including 2x individual counseling weekly. This training also discussed the importance of documentation when the client is absent from the individual counseling at the scheduled individual counseling appointment.
The Facility Director will perform a weekly audit of all progress notes at PHP level of care to ensure compliance. |
709.83(a)(9) 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:
(9) 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 four of seven records reviewed.
Client # 1 was admitted on August 18, 2023 and was transferred to a lower level of care on September 12, 2023. The record contained a progress note for two group sessions occurring on August 21, 2023, that were not completed until August 28, 2023 and August 30, 2023.
Client # 2 was admitted on October 9, 2023 and was transferred to a lower level of care on November 21, 2023. The record contained progress notes for group sessions occurring on October 10, 2023, October 31, 2023, and November 13, 2023, that were not completed until October 19, 2023, November 6, 2023, and November 27, 2023, respectively.
Client # 4 was admitted on August 14, 2023 and was transferred to a lower level of care on September 6, 2023. The record contained progress notes for group sessions occurring on August 17, 2023, August 21, 2023, and August 25, 2023, that were not completed until August 24, 2023, August 30, 2023, and September 5, 2023, respectively. Additionally, the record contained a progress note for an individual session occurring on September 1, 2023, that was not completed until September 9, 2023.
Client # 7 was admitted on November 6, 2023 and was transferred to a lower level of care on December 4, 2023. The record contained progress notes for individual sessions occurring on November 15, 2023, November 17, 2023, November 20, 2023, and November 27, 2023, that were not completed until November 29, 2023, December 4, 2023, December 4, 2023, and December 11, 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 records policy with all clinical staff members 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 timeframe for all the clients in Partial Hospitalization level of care. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within three weeks of admission, in two of three applicable records reviewed.
Client # 9 was admitted on September 25, 2023 and was discharged on November 27, 2023. The client record did not contain a psychosocial evaluation.
Client # 15 was admitted on September 14, 2023 and was discharged on November 30, 2023. The psychosocial evaluation was not completed until October 13, 2023.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The clinical formation section of the biopsychosocial evaluation for client #9 and #15 were reviewed and completed on 1/26/24.
The Facility Director conducted a staff training on Care, Treatment and Services policy, focusing on the completion of biospychosocial evolution including clinical formation of the client to all the clinical staff members.
The Facility Director will require each primary therapist to verify the completeness of the biospychosocial evaluation form before they place their signature on the form, then submit to the Facility Director for final sign-off.
The Facility Director will perform a random monthly audit of completed biopsychosocial evaluation for all newly admitted clients to verify completeness. |
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 six of seven records reviewed.
Client # 8 was admitted on September 12, 2023 and was discharged on October 23, 2023. The treatment plan completed on September 11, 2023, indicated that the client was to receive 8 hours of group per week and one individual session per week; however, the record did not document any individual sessions offered after September 28, 2023 or group sessions offered after October 16, 2023.
Client # 9 was admitted on September 25, 2023 and was discharged November 27, 2023. The treatment plan completed on October 11, 2023, indicated that the client was to receive one individual session per week; however, the record did not contain documentation of an individual session the week of November 6, 2023.
Client # 10 was admitted on November 21, 2023 and was discharged on January 3, 2024. The treatment plan completed on November 21, 2023, indicated that the client was to receive one individual session per week; however, the record did not contain documentation of an individual session since November 14, 2023.
Client # 11 was admitted on January 4, 2019 and discharged on December 28, 2023. The treatment plans completed on September 26, 2023 and November 28, 2023, indicated that the client was to receive one individual session per week; however, the record did not contain documentation of individual sessions between October 11, 2023 and November 8, 2023, or between November 8, 2023 and December 6, 2023.
Client # 12 was admitted on August 28, 2023 and was active at the time of the inspection. The treatment plan completed on October 5, 2023, indicated that the client was to receive one individual session per week; however, the record did not contain documentation of an individual session between October 5, 2023 and October 26, 2023.
Client # 13 was admitted on September 6, 2023 and was active at the time of the inspection. The treatment plans completed on September 6, 2023 and October 29, 2023, indicated that the client was to receive one individual session per week; however, the record only contained documentation of two individual sessions between September 29, 2023 and December 30, 2023.
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 and client records policies 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 documentation of such care being offered, even in the case when the client is not available to receive care.
The Facility Director will perform random monthly audit of all progress notes to ensure the clients receive care according to their treatment plan as well as documentation of care delivery. |
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 six records reviewed.
Client # 9 was admitted on September 25, 2023 and was discharged November 27, 2023. The record contained progress notes for group sessions occurring on October 30, 2023 and November 6, 2023, that were not completed until November 5, 2023 and November 12, 2023, respectively.
Client # 14 was admitted on October 16, 2023 and was active at the time of the inspection. The record contained progress notes for a group session occurring on November 30, 2023, and an individual session occurring on December 13, 2023, that were not completed until December 6, 2023 and December 19, 2023, respectively.
Client # 15 was admitted on September 16, 2023 and was transferred on November 30, 2023. The record contained progress notes for group sessions occurring on October 23, 2023, November 13, 2023, and November 20, 2023, that were not completed until October 29, 2023, November 18, 2023, and December 6, 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 monthly audit to ensure all progress notes are completed within the required timeline.
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