INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on August 7, 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(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 8am to 9pm Monday through Friday and there was only certification provided for one staff member, who works 40 hours per week, that is trained in CPR and First Aid. This is a repeat citation from the March 28, 2023 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer has coordinated an all-staff training for CPR & First Aid (8 total staff members) by contracting with a private and credentialed training company. The all-staff training will be completed by November 1st, 2023.
Chief Clinical Officer has established weekly meetings with the management team and ownership to address DDAP regulations, Status of Plans of Correction, Compliance, Updates to P & P, staff and facility training plans, etc. These weekly meetings are intended to provide an organized approach to and oversight of programmatic compliance with DDAP Regulations. The weekly meetings, participants, and agenda items will be documented and stored in a 3-ring binder, which will be located in the office of the Chief Clinical Office. Meetings are held every Monday at 3pm. |
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 a complete client record, which is to include follow-up information, in three of five applicable client records reviewed.Client # 6 was admitted on April 25, 2023 and was discharged on June 14, 2023. The client record did not document follow-up information as of the date of the inspection.Client # 9 was admitted on May 15, 2023 and was discharged on June 26, 2023. The client record did not document follow-up information as of the date of the inspection.Client # 10 was admitted on April 12, 2023 and was discharged on July 10, 2023. The client record did not document follow-up information as of the date of the inspection.This is a repeat citation from the March 28, 2023 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BHT Support Staff has started contacted previously discharged clients as part of of our alumni/ follow-up tracking based on our Policy & Procedures. BHT Support Staff will place phone calls to clients at 30, 60, 90, 120, and 365 days post discharge for alumni/ follow-up contact to assess efficacy of program and client stability post-discharge. Brief Assessments of Recovery Capital (BARC-10) will be conducted during these phone calls. If the client is unreachable an alumni/ follow-up letter will be sent with instructions to contact the facility and complete a BARC-10. A copy of the letter will be upload into each chart with date. time of letter sent. If an alumni/ follow-up call is successful it will be documented in each client chart. Clinical Supervisor will include alumni/ follow-up attempts and documentation during bi-weekly chart audits and will report her findings to Chief Clinical Officer during weekly DDAP management & compliance meetings. |