INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2025 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 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 three applicable personnel records reviewed.Employee # 8 was hired as a counselor assistant on April 3, 2023 and was due to receive the HIV/AIDS training and the TB/STD training no later than April 3, 2024. There was appropriate documentation of receiving the HIV/AIDS training; however, there was only 1 hour of the TB/STD training documented 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 #8 is scheduled to attend the TB/STD training provided by BHTEN on 3/28/2025 from 9:00am to 1:00pm, which will meet the 4 hour requirement.
Clinical Director (Facility Director) has implemented a spreadsheet with due dates for completion of all required trainings for all staff members, and will review completion certificates with the Quality Improvement team to ensure compliance for all staff to prevent recurrence. |
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 a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of fifteen applicable client records reviewed.Client #13 was admitted to the outpatient activity on June 17, 2024 and was discharged on October 17, 2024. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As part of our effort to continue to improve quality and efficiency, the Quality Improvement team, headed by the Director of Clinical Services (Project Director) and the Clinical Director (Facility Director) will review intake documentation to ensure accuracy and completeness of all required consents. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of fifteen applicable client records reviewed.Client #6 was admitted to the partial hospitalization activity on September 18, 2024 and was discharged on November 1, 2024. A release of information form to a physician was signed and dated by the client on September 17, 2024; however, there was no name of the person, agency or organization to whom the disclosure was to be made included on the release form. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As part of our effort to continue to improve quality and efficiency, the Quality Improvement team, headed by the Director of Clinical Services (Project Director) and the Clinical Director (Facility Director) will review intake documentation to ensure accuracy and completeness of all required consents. |