INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from January 13 - 16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Livengrin Foundation, Inc. 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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705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit. The facility also failed to ensure that there was a slip-resistant surface in all bathtubs and/or showers.
The findings include:
A physical plant inspection was conducted on January 16, 2014 at approximately 10:00 AM. During the inspection, the water temperature in cottage F measured 125 degrees in bathrooms # 102 and 103 and the water temperature in the female bathroom on the lower level of D-Wing was 128 degrees Fahrenheit. Additionally, the facility failed to provide slip-resistant surfaces in the showers contained in bathrooms # 105 and 109.
The Director of Maintenance confirmed the findings.
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Plan of Correction
The Facilites Director will ensure that the below 120 degrees fahrenheit. He will check it every week. His staff will check it every day. The Facilities Director will make sure that there were slip resistant surfaces in all bathtubs and showers. He will check every week. The water temperature has been reduced. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on observation during the annual licensing inspection, the facility failed to maintain the confidentiality of client identities.
The findings include:
The annual licensing inspection began on January 13, 2014 at approximately 9 AM. Upon arriving at the facility, Licensing staff observed that there was a sign-in sheet at the entrance to the facility. The facility failed to maintain the confidentiality of client identities as the sign-in sheet included a list of client first and last names.
The Quality Assurance Director confirmed that the sign-in sheet included the client's first and last name.
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Plan of Correction
The Receptionist and her supervisor will make sure that the last name is not on the sign-in sheet. If it is, they will eliminate the last name, by crossing it out. It is only supposed to be the patient's letter for the patient's last name. This will be revised to only include the last initial of the patient's last name. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services in three out of six inpatient client records.
The findings include:
Six inpatient client records were reviewed for documentation of treatment plans on January 14, 2013. Three out of six inpatient client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 1, 3, and 6.
The treatment plan for client #1 was completed on December 30, 2013 and did not include the frequency of treatment and rehabilitation services.
The treatment plan for client #3 was completed on October 8, 2013 and did not include the type and frequency of treatment and rehabilitation services.
The treatment plan for client #6 was completed on November 13, 2013 and did not include the type and frequency of treatment and rehabilitation services.
The findings were discussed with facility staff prior to the exit interview.
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Plan of Correction
The Facility Director and the supervisors will ensure that every treatment plan will include Type and Frequency of the rehabilitation services. Supervisors will train staff. The Facility Director is responsible for oversight. The facility will be in full compliance with the standard. It will be on our Licensing Checklist for the 2014 visit. Each treatment plan will be reviewed by supervisory staff, to include type and frequency of services. It cannot be added to the Sigmund treatment plan. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in two out of six inpatient client records.
The findings include:
Six inpatient client records were reviewed for documentation of treatment plans on January 14, 2013. Two out of six inpatient client records lacked documentation of a treatment plan that included proposed types of supportive services, specifically client records # 1 and 2.
The treatment plan for client # 1 was completed on December 30, 2013 but did not include proposed types of supportive services for client #1.
The treatment plan for client # 2 was completed on December 26, 2013 but did not include proposed types of supportive services for client #2.
The findings were discussed with facility staff prior to the exit interview.
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Plan of Correction
The Facility Director and the supervisors will ensure that the support services will be included in every treatment plan. The supervisors will train staff. They will make sure that the support services are included in every treatment plan. The Facility Director is responsible for oversight. The facility will be in full compliance with the standard. It will be on our Licensing Checklist for the 2014 visit. Support services will not be added to Sigmund. It is difficult to add to the treament plan in Sigmund. The supervisors will check every treatment plan to make sure that the support services are included. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in
three out of five inpatient client records where required.
The findings include:
The facility's recommended length of treatment is 21 days.
Six inpatient client records were reviewed on January 14, 2013. Five of those records required documentation of a treatment plan update within 15 days. Two out of five inpatient records lacked documentation of a treatment plan update, specifically client records # 2 and 3.
Client # 2 was admitted on December 20, 2012. The treatment plan for client # 2 was completed on December 26, 2013. An update was due by January 10, 2014. As of the date of inspection, there was no documentation of a treatment plan update for client # 2.
Client # 3 was admitted on October 2, 2012. The treatment plan for client # 3 was completed on October 8, 2013. An update was due by October 23, 2013. As of the date of inspection, there was no documentation of a treatment plan update for client # 3.
The findings were discussed with the facility staff prior to the exit interview.
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Plan of Correction
The Facility Director and the supervisors will ensure that the Treatment Plan Update is completed within 15 days of the Master Treatment Plan. The supervisors will look at every chart. The staff will be trained to do the Update Treatment Plan within 15 days. The Facility Director is responsible for oversight. The facility will be in full compliance with the standard. It will be on a Licensing
Checklist for the 2014 visit. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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
one out of two inpatient client records where required.
The findings include:
Six inpatient client records were reviewed on January 14, 2013. Two of those records required documentation of follow-up information. One out of two inpatient client records lacked documentation of follow-up information, specifically record # 3.
Client #3 was discharged on October 27, 2013. Documentation of a follow-up was due by November 27, 2013. As of the date of inspection, there was no documentation of follow-up information for client #3.
The findings were confirmed by clinical staff prior to the exit interview.
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Plan of Correction
The Director of Compliance and Licensing will make sure the follow-up staff member is doing follow-up of every patient. She will be trained as a reminder. The Director of Licensing and Compliance is responsible for Oversight. The facility will be in full compliance with the standard.
The client #3 has been reached out to for follow-up. It was done on 1/17/14. |
709.14(b)(5) 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:
(5) Change in authorized maximum capacity.
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Observations
Based on observation during a physical plant inspection and an interview with the Project Director, the facility failed to comply with the maximum approved capacity.
The findings include:
A physical plant inspection was conducted on January 16, 2014 at approximately 10 AM.
The facility is licensed by the Division for a maximum client capacity of 83 inpatient non-hospital drug-free beds and 21 detox beds, for a combined total of 104 beds.
The facility exceeded the licensed maximum capacity as there were 109 beds in the facility at the time of inspection. The detox unit had 5 additional beds.
The facility requested an exception on December 5, 2013, and failed to comply with details outlined in the exception request dated for December 12, 2013. The exception request stated:
"In regards to your letter of December 5, 2013, you are requesting an exception to regulation 705.5 for sleeping accommodations. You request that up to six licensed beds for Detoxification services be available for use as Residential Rehabilitation beds until licensed Rehabilitation beds become available.
Your facility is approved for 6 Inpatient Non-Hospital Detoxification beds and 6 Inpatient Non-Hospital Drug-Free beds to be used for flexing detoxification and residential beds.
Please note that the facility may not exceed the total capacity of 104 beds as per your request in your letter."
During an interview, the Project Director confirmed that the additional 5 beds were set up after the approved exception request which specified that the facility may not exceed the total capacity of 104 beds.
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Plan of Correction
The Facility Director submitted the request within 90 days. They added five beds to Detox. We have our license now for 109 beds. The Project Director and the Facility Director will make sure that the flex beds are used properly. The Facility Director will be resposible for the training of staff. The Facility Director will have oversight over the flex beds. we will be in full compliance of the standard. |