INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 28, 2020 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CEO is currently working with DDAP staff/ licensing specialist supervisor to obtain changes to error in letter submitted to the state, pre-audit, that would allow the facility to waive the need to obtain an outside audit from a public accountant due to revenue being under $500,000 a year.
In the event that letter is not obtained, facility will obtain an outside independent public accountant to audit financial activities. |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in four of seven client records. Client # 3 was admitted on December 3, 2019 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form on file prior to disclosure. Client # 4 was admitted on September 30, 2019 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form on file prior to disclosure. Client # 5 was admitted on November 25, 2019 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form on file prior to disclosure. Client # 6 was admitted on June 11, 2019 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form on file prior to disclosure. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Code 255.5 was reviewed with clinical staff & administration during an all staff meeting on 03/10/2020. 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.
Client #3, release to funding source has been changed to be in compliance with 4 Pa. Code 255.5 (b).
Client #5; release of information has been appropriately added to clients chart.
Client #6; release of information for funding source has been added to client chart.
Client #4 has been discharged.
Charts will be reviewed monthly by the Project Director 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 the review of client records, 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 three of three applicable client records. Each consent to the funding source allowed for the release of psychosocial data and assessment, discharge summary, aftercare plan, all clinical progress notes and treatment plans, and all correspondence contained in record.Client # 1 was admitted on March 20, 2019 and was active at the time of the inspection.Client # 2 was admitted on March 11, 2019 and was active at the time of the inspection.Client # 7 was admitted on March 1, 2019 and was discharged on June 1, 2019.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During clinical and administrative team meeting on 3/10/2020, all staff reviewed PA CODE 255.5 surrounding information that is able to be released to funding sources.
All staff were advised that moving forward that release of psychological data, assessment, discharge summary, aftercare plan, and clinical progress notes/treatment plans are not to be released to funding sources directly from facility. This compliance plan will be monitored by Facility Director.
All staff were advised that only the two first areas of a consent to release information is to be released to funding sources, by the Facility Director.
All staff agreed and acknowledged this feedback.
Moving forward, all funding source consents will be marked appropriately. A specific consent for funding sources will be uploaded in Kipu to
mitigate any user error.
The Facility Director will be responsible for monitoring all charts on a monthly basis.
Client #1 has been discharged since the audit.
Client #2 has been discharged since the audit.
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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 the review of client records, the facility failed to properly document the type of services the client was to receive on the client's individual treatment plan in each client record reviewed. Additionally, the facility failed to follow the written procedures for the management of treatment/rehabilitation services, as individualized treatment plans were developed late in four of seven client records.Client # 1 was admitted on March 20, 2019 and was active at the time of inspection. The written procedure manual stated that the master treatment plan must be developed within 14 days from the date of admission; however, the treatment plan was not developed until May 20, 2019.Client # 2 was admitted on March 11, 2019 and was active at the time of inspection. The written procedure manual stated that the master treatment plan must be developed within 14 days from the date of admission; however, the treatment plan was not developed until June 19, 2019.Client # 3 was admitted on December 3, 2019 and was active at the time of the inspection. The comprehensive treatment plan was dated December 12, 2019. Client # 4 was admitted on September 30, 2019 and was discharged on February 4, 2020. The comprehensive treatment plan was dated October 8, 2019.Client # 5 was admitted on November 25, 2019 and was discharged on January 7, 2020. The written procedure manual stated that the master treatment plan must be developed within 14 days from the date of admission; however, the treatment plan was not developed until December 17, 2019.Client # 6 was admitted on June 11, 2019 and was discharged on November 12, 2019. The written procedure manual stated that the master treatment plan must be developed within 14 days from the date of admission; however, the treatment plan was not developed until July 3, 2019.Client # 7 was admitted on March 1, 2019 and was discharged on June 1, 2019. The comprehensive treatment plan was dated March 8, 2019.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
During a clinical & administrative team meeting, led by Facility Director, on 3/10/2020, the expectation was laid out as such:
1. Each treatment plan will have a long-term goal, short-term goal, method of intervention, and clear modality of treatment (individual sessions, group sessions, family sessions) entered by the treating clinical staff member.
2. Each treatment plan will address the frequency of each intervention & modality (1x a week, 3x a week, or 2x a month).
3. Written procedures are currently being reviewed and Initial Treatment Plans & Comprehensive treatment plans, moving forward from 2/28/2020, will be in compliance with DDAP's time frame of completion of initial treatment plan on admission and comprehensive treatment plan immediately after the initial treatment plan has ended.
4. All treatment plans will be reviewed and updated every 60 days, in accordance with the state mandates.
5. Written procedures will be updated to reflect the DDAP state mandates for treatment plan creation and revision.
Facility Director will audit and monitor charts to remain compliant with this plan of correction monthly.
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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
Based on the review of client records, the facility failed to provide a complete client record, which is to include case consultation notes and follow-up information, in six of seven client records.Client # 1 was admitted on March 20, 2019 and was active at the time of inspection. The record was missing documentation of the completion of a case consultation.Client # 2 was admitted on March 11, 2019 and was active at the time of inspection. The record was missing documentation of the completion of a case consultation.Client # 4 was admitted on September 30, 2019 and was discharged on February 4, 2020. The record was missing documentation of the completion of a case consultation.Client # 5 was admitted on November 25, 2019 and was discharged on January 7, 2020. The record was missing documentation of follow-up information.Client # 6 was admitted on June 11, 2019 and was discharged on November 12, 2019. The record was missing documentation of follow-up information.Client # 7 was admitted on March 1, 2019 and was discharged on June 1, 2019. The record was missing documentation of follow-up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The case consultation form was reviewed with all clinical staff & administrative staff on 3/10/2020.
All charts moving forward immediately will include completed case consultation forms for each client per every 90 days of treatment.
A form has been created and is placed in Kipu, the EMR for Limitless, and will be used immediately moving forward.
The Facility Director will continue to conduct monthly chart reviews to ensure the completion of all necessary documentation in a timely manner.
Client #1 has been discharged since audit. A follow-up will occur in 30 days from discharge.
Client #2 has been discharged since audit. A follow-up will occur in 30 days from discharge.
Client #4 has been discharged. A 30 day follow-up of needs has occurred.
Client #5 has been discharged. A 30 day follow-up of needs has occurred.
Client #6 is discharged.
Client #7 is discharged.
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