INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 2023 through March 28, 2023 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedure manual and a discussion with the project driector, the facility failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of, an assignment of staff training needs, an overall plan for addressing these needs, a mechanism to collect feedback on completed training and an annual evaluation of the overall training plan. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer will develop, in collaboration with all staff members, an annual training plan that must be completed within the annual training timeframe. The training plan must include at least 25 hours of training for clinical staff and appropriate trainings for support staff, each signed off on by both the Chief Clinical Officer, support supervisor if needed, and staff member respective of their individualized plan. The training plan will be reviewed for progress at each weekly DDAP Compliance Management Meeting. Clinical staff members assume full responsibility to earn hourly trainings (min. of 25) within the established time-frame to uphold the plan of correction and policy and procedure outlining annual clinical staff trainings. All staff will provide documentation/ certification of completion for trainings outlined in annual training plan, which will be placed in employee file. This regulation will be added to Policies and Procedures as requirement for all staff. This update will occur by 05/03/2023 |
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 personnel records, the facility failed to ensure that CPR certification and first aid training was 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 operations. The facility's hours of operation are Monday through Friday from 8am to 9pm. The project only has one staff member CPR certification and first aid trained as of the date of the inspection.This is a repeat citation from the April 4, 2022 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Clinical Officer has identified that the facility development plan will include a staff-wide CPR & First Aid training. This will be completed within the next 6 months and will be a required training for all staff. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on an attempted review of personnel records, the facility failed to provide documentation that all staff were trained in the use of the fire extinguisher upon employment in two of two personnel records reviewed.Employee # 1 was hired as The Project Director on February 12, 2022. There was no documentation of training in the use of fire extinguishers at the time of the inspection. Employee # 2 was hired as the Facility Director/Clinical Supervisor/Counselor on December 13, 2022. There was no documentation of training in the use of fire extinguishers at the time of the inspection. This is a repeat citation from the April 4, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Operating Officer will be attending the monthly DDAP Compliance and Planning meetings and is responsible for conducting and maintaining fire extinguisher training and documentation for all staff. Employees 1 & 2 have completed tfire extinguisher raining and their employee files have been updated with the corresponding documentation. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the August 2022 through March 2023 fire drill logs, the facility failed to conduct an unannounced fire drill, at least one time a month, during the month of February 2023.This is a repeat citation from the April 4, 2022 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Chief Operating Officer will be attending the monthly DDAP Compliance and Planning meetings and is responsible for conducting monthly fire drills and maintaining documentation of each drill with pertaining information in the Fire/ Emergency Drill Log. Monthly fire drills and all pertaining information will be reviewed by the management team at the monthly DDAP Compliance and Planning meetings to ensure alignment with DDAP regulations. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in two of two personnel records reviewed.Employee # 1 was hired as The Project Director on February 12, 2022. There was no documentation of training on the assignment of tasks during emergencies as of the date of the inspection. Employee # 2 was hired as the Facility Director/Clinical Supervisor/Counselor on December 13, 2022. There was no documentation of training on the assignment of tasks during emergencies as of the date of the inspection. This is a repeat citation from the April 4, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Operating Officer will be attending the monthly DDAP Compliance and Planning meetings and is responsible for conducting training for each staff member on assigned tasks during emergencies and maintaining documentation for all staff new and existing in respective employee files. Employees 1 & 2 have completed training on assigned tasks during emergencies and their employee files have been updated with the corresponding documentation.
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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 the facility's August 2022 through March 2023 fire drill logs, the facility failed to ensure that alternate exit routes were prepared and used during fire drills as only one exit was used for every drill conducted during the reviewed period. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the building's design there is only one entrance and exit for the clinical building but there is an egress exit that needs a ladder to be functioning as an emergency exit. Chief Clinical Officer and Program Director are currently working on purchasing a safety ladder for emergency exit via the egress, located on the lower floor of the clinical building. Once purchased and functioning the emergency exit will be utilized during random monthly fire drills and be documented along with other pertinent information, to be stored in the Fire/ Emergency Drill Log. This log is to be maintained by the Chief Operating Officer and reported on at each monthly management meeting for DDAP Compliance and Planning. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's August 2022 through March 2023 fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill for every fire drill conducted during the reviewed period. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer will submit a letter to DDAP requesting dispensation related to a facility fire alarm or smoke detector. The letter, which will be submitted by 05/03/2023 will be asking for the allowance of an air-horn to simulate a fire alarm or smoke detector due to the facility being shared with multiple businesses. If approved, the utilization of an air-horn will be documented in the Fire/ Emergency Drill Logfor each completed drill. If the request is not approved by DDAP, Chief Clinical Officer will meet with building management/ owner and local fire department to request utilization of building fire alarm during drills. |
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 an administrative review, the facility failed to 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. The facility has a DDAP-approved exception, per Licensing Alert 01-11, however, the project failed to provide the most recent tax return, in accordance with the exception approval.This is a repeat citation from the April 4, 2022 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CEO has notified the independent certified public accountant who was been retained to maintain financial records, taxes, audits, etc. that 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 is due for fiscal year 2022. CPA has been notified to include previously missed audits for years prior to and including 2022.
CEO will submit all outstanding fiscal audits to DDAP when they are received by CPA via email.
Moving forward CEO will request CPA to complete a fiscal audit within 6 months of the end of that fiscal year. Oour DDAP Compliance Management Team has included this regulation in its weekly meetings as a permanent agenda item that willreviewed to assure this regulation is met during each subsequent inspection. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel files, the facility failed to ensure that annual written individual performance evaluations, reviewed and signed by the employee, were completed in one of one applicable personnel record reviewed.Employee #1 was hired as the project director on February 12, 2022. There was no documentation that the annual written individual performance evaluation was completed for the prior year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer will develop, in collaboration with all clinical management and staff an annual training plan that will require at least 25 hours of completed trainings that satisfy training needs. Each clinical staff manager and member can earn CEUs in the following domains: (i) Supervision and evaluation. (ii) Counseling techniques. (iii) Substance abuse trends and treatment methodologies in the field of addiction. (iv) Confidentiality. (v) Codependency/Adult Children of Alcoholics (ACOA) issues. (vi) Ethics. (vii) Interaction of addiction and mental illness. (viii) Cultural awareness. (ix) Sexual harassment. (x) Developmental psychology. (xi) Relapse prevention. (xii) Disease of addiction. (xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
All annual training plans for existing and new clinical employees will be reviewed at each monthly DDAP Compliance and Planning Meeting. |
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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed. Client # 1 was on December 2, 2022 and was active at the time of inspection. The release of information form to the funding source was signed by the client and witness on December 2, 2022 and it expired on March 2, 2023. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after March 2, 2023.Client # 3 was on July 25, 2022 and was active at the time of inspection. The release of information form to the funding source was signed by the client and witness on July 25, 2022 and it expired on October 23, 2022. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after October 23, 2022.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Chief Clinical Officer informed the Chief Operating Officer and Director of Admissions to facilitate and/or train support/ admissions staff on the proper completion of informed and voluntary consent for release of confidential information to
These releases must be active for 365 days from signed consent, unless declined by the client
Moving forward, Chief Clinical Officer has included ROIs in chart audits for compliance. This information will be reviewed at the monthly DDAP Compliance and Planning meetings conducted by the management team.
All active clients now have signed updated ROIs. |
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 client records, the facility failed to maintain a complete client record, which is to include follow up information, in two of two applicable client records reviewed.Client #4 was admitted September 12, 2022 and was successfully discharged February 9, 2022. There was no follow-up information documented in the record at the time of the inspection.Client #6 was admitted October 24, 2022 and was successfully discharged February 10, 2023. There was no follow-up information documented in the record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer developed and implemented a new evidence-based tracking tool. The tool has already been built into our EMR system and is being utilized with each new client upon meeting with their Primary Therapist (PT). The PT will complete this tool within 72 hours of admission, then again at 2 weeks, again at 30 days, 60 days, 120 days upon discharge, and then 365 days after discharge. This process has already started and is part of the weekly auditing completed by Chief Clinical Officer to maintain compliance. |
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 maintain a complete client record, which is to include case consultation notes, in seven of seven applicable client records reviewed.In every client record reviewed, there was no documentation of case consultation notes in the record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer has developed a mechanism for conducting and documenting case consultations. During each client's utilization review for level of care, the primary therapist, the medical director, support staff, and clinical management will contribute to case consultation, which will be completed a signed-off on in each client's electronic medical record. These case consultations are to be included in chart audits and reviewed during the monthly DDAP Compliance & Planning meetings. |
709.14(b)(1) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
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Observations
Based on an administrative review, the facility failed to notify the department, in writing, 90 days of the occurrence of a change of ownership. There was documentation that the facility sent a letter stating that there was a change in ownership on March 31, 2022. However, the facility failed to provide additional, required information to allow the Department to review and process the change of ownership as of the date of the inspection conducted on March 27, 2023 through March 28, 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The required documentation has been submitted to DDAP on 4/27/23 to complete the change of ownership and management. Once approved by DDAP. The management team will review any anticipated changes in ownership and/or management at the monthly DDAP Compliance and Planning meetings to ensure that all required forms related to a change in ownership and/or management are submitted to DDAP within 90 days. This is the responsibility of the Chief Clinical Officer.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on an administrative review, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction documenting that the facility would obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the projects drug/alcohol abuse services or comply with a written exception approval were submitted and approved by the Department for the April 4, 2022 and September 6, 2022 licensing inspections. Failure to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the projects drug/alcohol abuse services or comply with a written exception was again found to be a deficiency in the March 27, 2023 - March 28, 2023 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CEO has notified the independent certified public accountant who was been retained to maintain financial records, taxes, audits, etc. that 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 is due for fiscal year 2022. CPA has been notified to include previously missed audits for years prior to and including 2022.
CEO will submit all outstanding fiscal audits to DDAP when they are received by CPA via email.
Moving forward CEO will request CPA to complete a fiscal audit within 6 months of the end of that fiscal year. Oour DDAP Compliance Management Team has included this regulation in its weekly meetings as a permanent agenda item that willreviewed to assure this regulation is met during each subsequent inspection. |