INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of two applicable personnel records reviewed. Employee # 2 was hired as a counselor on May 29, 2019 and was due to have HIV/AIDS training and TB/STD training no later than May 29, 2020. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 will be registered for HIV/AIDS training through BHTEN on 4/26/2021 for a training on 6/8-9/21.
BHTEN opens registration 6 weeks before and conversation has been held with BHTEN training coordinator for DDAP training notices.
Employee #2 will be registered for TB/STD in June 2021 when BHTEN offers DDAP training schedule.
Facility is also creating a training working relationship with DDAP licensed facility to increased shared training options to meet yearly licensing requirements.
To ensure no re-occurance of deficiency, Clinical Director will schedule all new hires, without required DDAP trainings, one month upon hire.
Clinical Director will monitor training files monthly to audit for training surveys and completion certificates. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2019 through June 30, 2020 training year.Employee #2 was hired as a counselor on May 29, 2019. The personnel record documented 20.5 hours of training during the reviewed training year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will revise training plan to ensure a minimum of 2 hours of training per month.
Trainings can occur in-person or online. Clinical Director will collect training log monthly to have better tracking system for end-of-year training review.
Revised training binder with certificate and feedback forms created in April 2021. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. At approxmately 1:15 PM on April 1, 2020, a physical plant inspection revealed that all of the fire extinguishers in the facility were tagged documenting that they had last been inspected in February 2020. This findings was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire extinguishers will be inspected on 4/16/21.
Moving forward to prevent a lapse in inspection of fire extinguishers, management team will log date with monthly fire drills. 30 days prior to expiration, next appointment for inspection will be scheduled. |
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 client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in two of seven client records reviewed. Client # 2 was admitted on January 21, 2021 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client on February 15, 2021, that allowed for the release of psychosocial data and assessment, discharge summary, aftercare plan and all clinical progress notes and treatment plans, all of which exceeded the limits established by 4 Pa. Code 255.5. Client # 3 was admitted on March 11, 2021 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client on March 11, 2021, that 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 the record, all of which exceeded the limits established by 4 Pa. Code 255.5. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #2 has re-signed a release of information to their funding source. Release was completed with appropriate information to be released in accordance to 4 Pa. Code 255.5
Previous release of information was voided and discarded.
Client #3 has re-signed a release of information to their funding source. Release was completed with appropriate information to be released in accordance to 4 Pa. Code 255.5
Previous release of information was voided and discarded.
Additionally, clinical director has held brief training for all staff around information to be released to funding sources to meet requirements of 4 Pa. Code 255.5.
For continued monitoring and compliance, Clinical Director will conduct weekly chart audits specifically looking at release of information and consents for compliance for Code 255.5.
Upon completion of intakes, clinical director will also review.
For ongoing training and staff education, during monthly staff meetings, Clinical Director will review releases of information with staff.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to ensure that all informed and voluntary consent to release information forms documented the dated signature of the witness at the same time of the client signature on release of information forms in five of seven client records reviewed.Client # 1 was admitted on August 17, 2020 and was still active at the time of the inspection. Release of information forms to a primary care physician, a funding source and an emergency contact were all signed by the client on August 17, 2020; however, all of the consent forms were not signed by the witness until August 18, 2020.Client # 2 was admitted on January 21, 2021 and was still active at the time of the inspection. A release of information form an emergency contact was signed by the client on January 22, 2021; however, there was no witness signature documented on the form.Client # 5 was admitted on April 27, 2020 and was discharged on October 16, 2020. Release of information forms to a funding source and an emergency contact were signed by the client on April 27, 2020; however, there was no witness signature documented on any of the forms.Client # 6 was admitted on September 21, 2020 and was discharged on February 3, 2021. Release of information forms to a funding source, another treatment provider and an emergency contact were signed by the client on September 21, 2020; however, all of the consent forms were not signed by the witness until September 22, 2020.Client # 7 was admitted on August 24, 2020 and was discharged on December 8, 2020. Release of information forms to a funding source, other treatment providers and an emergency contact were signed by the client on August 24, 2020; however, there was no witness signature documented on any of the forms.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client # 1's releases of information for primary care physician, funding source and emergency contact were redone with witness signature to be valid.
Client # 2 releases of information for primary care physician, funding source and emergency contact were redone with witness signature to be valid.
Clients #5, 6, 7 are discharged.
Individuals responsible and plan for ongoing compliance: Therapist is responsible for ensuring that all releases of information are completed within 24 hours of client signing.
During weekly chart audits completed by the clinical director, responsible for compliance monitoring, will check all new admission releases of information and will document any compliance issues with therapist the next business day for immediately rectifying. |
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 document follow up information in the client record in two of four applicable client records reviewed. Client # 6 was admitted on September 21, 2020 and was discharged on February 3, 2021. The client record failed to document follow up information regarding the client as of the date of the inspection. Client # 7 was admitted on August 24, 2020 and was discharged on December 8, 2020. The client record failed to document follow up information regarding the client as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow-up reviews should occur 30 days after discharge.
Facility has assigned 30 day discharge follow-ups with CRS and will log in "case management notes" until clients clinical file.
All 30 day follow-ups will continue to occur via phone.
Compliance monitoring methods: Upon signing of discharge paper, clinical director will enter discharge date into a HIPPA compliant spreadsheet to track time after discharge to 30 day follow-up. 30 day follow-ups will be assigned to staff via spreadsheet. Staff member will be tasked with completing a case management note in the EMR to denote the contact has been attempted. Sheet will be updated and clinical director will check KIPU system 24 hours post discharge follow-up to ensure compliance with follow-up. |