INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 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 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of four personnel records, the facility failed to demonstrate that a sufficient number of staff persons had CPR certification as only one staff member was certified in CPR between March 2022 and December 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has and does maintain at least one staff member who is CPR certified onsite during our hours of operation. We propose that our services be delivered via telehealth when the trained staff person becomes unavailable. An exception request letter was submitted to DDAP for consideration on 3/7/23 to this effect.
Additionally, as of 3/23/23, all clinicians and supporting staff person working at this office location are CPR trained.
Going forward, the facility director will require all staff persons including supporting staff to be CPR trained and maintained at this office location. All new hires (both clinical and non clinical staff) are required to complete the CPR training within the first week of hire which is reflected in our policy.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from March 2022 through January 2023, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility did and continue to perform monthly fire drill using alternate staircase as an exit route. The fire drill log did not specify which staircase was used for fire drill. Facility Director will provide training with staff members by 2/28/23 to be specific on which staircase (North or South) is used as an exit route on the fire drill log that starting 3/1/23, the fire drill log will specify which staircase is used.
Facility Director will perform a quarterly audit to ensure proper staircase is documented on the fire drill log. |
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 policies and discussion with staff, the facility failed to ensure that the written procedures for the management of treatment/rehabilitation services included timeframes for when the completion of progress notes were 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 will conduct training by 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. |
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 eight client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information in four records reviewed.
Client #3 was admitted on October 22, 2020 and was discharged on June 5, 2022. The consent to release information form to the funding source was not signed by the client until May 22, 2022; however, the record contained evidence of billing prior to that date.
Client #4 was admitted to the Outpatient level of care on January 6, 2022 and was discharged on December 6, 2022. The consent to release information form to the funding source was not signed by the client until May 25, 2022; however, the record contained evidence of billing prior to that date.
Client #6 was admitted to the Outpatient level of care on March 23, 2022 and was active at the time of the inspection. The consent to release information form to the funding source was not signed by the client until May 27, 2022; however, the record contained evidence of billing prior to that date.
Client #8 was admitted to the Outpatient level of care on July 18, 2022 and was active at the time of the inspection. The consent to release information form to the funding source was not signed by the client until May 27, 2022; however, the record contained evidence of billing prior to that date.
This is a repeat citation from the March 1, 2022 annual licensing inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director reviews our confidentiality policy and commits to improve the execution of obtaining the consent to release information from our clients. The delay of obtaining the signature from client #3, #4, #6 and #8 was partly due to the migration of the old form to the newly updated consent form which was approved by DDAP on 4/6/22. Facility Director will provide training to staff member by 2/28/23 about obtaining the consent to release from our clients to their insurance company within the first week of admission, preferably at the time of admission. This plan of correction is expected to be effective on 3/15/23.
Facility Director/Supervisor will ensure all ROIs pertaining to billing will be completed within the first week of admission and no contact with insurers will take place without a signed ROI, specific to their insurer. A monthly audit for all new admissions will be done by the Facility Director. |
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 a review of client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in eight of eight records reviewed.
Client #1 was admitted on August 15, 2022 and was discharged on December 29, 2022. The record contained a consent to release information form to the funding source signed by the client on July 26, 2022 that was missing the purpose of the disclosure.
Client #2 was admitted on April 20, 2022 and was discharged on August 9, 2022. The record contained a consent to release information form to the funding source signed by the client on April 21, 2022 that was missing the purpose of the disclosure.
Client #3 was admitted on October 22, 2020 and was discharged on June 5, 2022. The record contained a consent to release information form to the funding source signed by the client on May 22, 2022 that was missing the purpose of the disclosure.
Client #4 was admitted on January 6, 2022 and was discharged on December 6, 2022. The record contained a consent to release information form to the funding source signed by the client on May 25, 2022 that was missing the purpose of the disclosure.
Client #5 was admitted on July 18, 2022 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on June 6, 2022 that was missing the purpose of the disclosure.
Client #6 was admitted on March 23, 2022 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on May 25, 2022 that was missing the purpose of the disclosure.
Client #7 was admitted on August 22, 2022 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on May 27, 2022 that was missing the purpose of the disclosure.
Client #8 was admitted on July 18, 2022 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on January 2, 2023 that was missing the purpose of the disclosure.
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 corrected immediately and updated to include purpose of the disclosure, particularly related to the funding source at the time of this inspection. Facility Director will provide training to staff member by 2/28/23 about the updated consent to release information form that includes the purpose of the disclosure to the funding source. This updated form will be effective on 3/15/23 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. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission dates and discharge dates within a specific time period requested.
The list of clients produced by the facility did not distinguish admission and discharge dates between this licensed facility and the project's second licensed facility.
This is a repeat citation from the March 1, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that a tracking tool is operational by 4/1/2023 that it will quickly provide the dates of service (active in each facility), transfer dates, admission dates and treatment episodes that the client receives at this facility.
The Facility Director will perform a monthly audit of this tracking tool for accuracy and consistency at this facility. |