INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2 - 5, 2009 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 and a plan of correction is due on March 9, 2009.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records and supervisory notes on February 2, 2009, and client records on February 4 and 5, 2009, the facility failed to document direct observation for one counselor assistant.
Findings:
Personnel records and documentation of supervision for three counselor assistants were reviewed on February 2, 2009. Client records were reviewed on February 4 and 5, 2009. Documentation of three months direct observation of counseling sessions was required for one of three counselor assistants reviewed. Employee #11 was hired on 11/12/08 as a counselor assistant with a high school diploma. Supervisory notes did not document direct observation from date of hire. A progress note dated 1/27/09 in client record #6 was signed only by the counselor assistant and there was no documentation of a counselor or supervisor being present.
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Plan of Correction
In a clinical meeting on 3/18/2009, the Clinical Director education will be provided to counselors that direct observation must be documented on supervision records for counselor asistants, and that any clinical documentation completed by counselor assistants must be cosigned by the supervising counselor. Compliance will be monitored by the Clinical Director on a monthly basis. The Director, TQM will be responsible for oversight. |
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, CPR certification and first aid training records on February 2 and 3, 2009, the facility failed to ensure that at least one person trained in CPR and first aid was onsite during the project's hours of operation.
Findings:
Personnel, CPR certification and first aid training records and the work schedule for the prior four weeks were reviewed on February 2 and 3, 2009.
Based on the documentation provided by the facility, the facility failed to ensure that at least one person trained in CPR was onsite during the the hours for the following dates: 12/29/08 for the 7-3 and 11-7 shifts, on 12/30/08 for the 7-3 shift, on 12/31/08 for the 7-3 and 11-7 shifts, on 1/4/09 for the 11-7 shift, on 1/12, 1/13 and 1/14//09 for the 11-7 shift, on 1/17 and 1/18/09 for the 11-7 shift, on 1/21/09 for the 7-3 shift, on 1/22/09 for the 11-7 shift, on 1/24/09 for the 7-3 shift and on 1/26 and 1/31/09 for the 11-7 shift.
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Plan of Correction
In a meeting with nursing and clinical supervisors, on 3/20/2009, the Clinical Director will provide education about the requirement that there will be at least one staff member for first, second and third shifts who is certified in CPR and First Aid. Compliance will be monitored on daily basis by nursing and clinical supervisors. Oversight will be provided by the Director, TQM. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plant inspection, the facility failed to store all trash, garbage and rubbish in covered containers.
Findings:
The physical plant inspection was conducted on February 4, 2009 between 10 AM and 12 PM. The facility failed to store all trash, garbage and rubbish in covered containers. There was an uncovered trash container on the outside by the kitchen door.
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Plan of Correction
By 3/13/2009, the Director of Facitilites Management will ensure that all trash, garbage and rubbish containers are covered. The Director of Facilities Management will monitor compliance on a weekly basis. Oversight will be provided by the Director of Administrative Services. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room.
Findings:
The physical plant inspection was conducted on February 4, 2009 between 10 AM and 12 PM. The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The large group room on the lower level and adjacent to the dining area had two walls of windows which did not have any coverings.
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Plan of Correction
On 2/27/2009,the Director of Facilities Management installed window coverings on the two windows that did not have any coverings. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in four of five client records.
Findings:
Nineteen client records were reviewed on February 4 and 5, 2009, of those nineteen records, five were partial hospitalization client records. Psychosocial evaluations were reviewed in five partial hospitalization client records on February 5, 2008. . The facility did not document a psychosocial evaluation to include the client ' s assets/strengths, support systems and negative factors in client records # 1, 2, 3 and 4.
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Plan of Correction
In a meeting on 3/18/2009, the Clinical Direcror will educate counselors that all required elements, including clients' assets/strengths, support systems and negative factors, must be included in psychosocial evaluations. Compliance will be monitored by the Clinical Director. Oversight will be provided by the Direcror, TQM. The Clinical Supervisor will review charts monthly. |
709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in two of two client records.
Findings:
Nineteen Client records were reviewed on February 4 and 5, 2009, of those nineteen records, five were for partial hospitalization clients. Five partial hospitalization client records were reviewed on February 5, 2008. A discharge summary was required in two partial hospitalization client records. The facility did not document a discharge summary in client records # 5 and 6.
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Plan of Correction
In a meeting on 3/18/2009, the Clinical Director will educate counselors of the need to complete a discharge summary for all patients. Compliance will be monitored on a monthly basis by the Clinical Director. Oversight will be provided by the Director, TQM. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to display to the public the hours of project operation.
Findings:
A physical plant inspection was conducted on February 4, 2009 at approximately 10:00 AM and February 5, 2009 at approximately 2:30 PM. The hours of project operation was required to be displayed conspicuously to the general public. The facility did not display the hours of project operation.
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Plan of Correction
By 3/20/2009, the Director of Administrative Services will display conspiculously to the general public, the hours of operation for the Bensalem site.. Oversight will be monitored by the Director, TQM. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of administrative documentation, the facility failed to document an annual report to include a statement disclosing the names of officers, directors and principal shareholders.
Findings:
Administrative documentation was reviewed on February 2, 2009. The facility failed to include the names of officers, directors and principal shareholders in an annual report.
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Plan of Correction
The Director, TQM will remind the PR Director of the need to disclose the names of officers, directors and principal shareholders in any subsequent annual reports. Compliance will be monitored by the Director, TQM. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based upon a review of client records and policies and procedures on February 2 - 5, 2009, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients.
The findings were:
The facility was combining the services of two distinctly different licensed activities by overlapping the services for clients in the Partial Hospitalization treatment program with the services of the clients in the Residential treatment program.
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Plan of Correction
By 4/15/2009, the Clinical Director will provide separate services for patients in the partial hospitalization program. Oversight will be provided by the Director, TQM. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to display a service fee schedule in a prominent place.
Findings:
A physical plant inspection was conducted on February 4, 2009 at approximately 10:00 AM and February 5, 2009 at approximately 2:30 PM. A service fee schedule was required to be posted in a prominent place. The facility did not display a service fee schedule.
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Plan of Correction
by 03/20/2009, the Director of Facilities Management will post a service fee schedule for the Bensalem site in a prominent place. Compliance will be monitored by the Director of Administrative Services. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document informed and voluntary consent from the client for the disclosure of information in nine of nineteen client records.
Findings:
Nineteen client records were reviewed on February 4-5, 2009. Informed and voluntary consent from the client for the disclosure of information was required in nineteen client records.
The facility documented correspondence with Atlantic Diagnostic Laboratories; however there was no signed Qualified Service Organization Agreement documented with Atlantic Diagnostic Laboratories on file, nor was there a documented consent to release information in the by the signed by the client in seven of nineteen records reviewed:
Inpatient detoxification client records # 2 and 3
Inpatient residential client records # 1, 4, 5 and 8
Partial hospitalization client record # 4
The facility documented a signed consent by the client for the release of information to the Pennsylvania Attorney General, but the information released exceeded the limitations of 4 Pa Code 255.5 in inpatient residential client records # 2, 3, 4 and 8.
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Plan of Correction
The Director, TQM will send a QSOA to Atlantic Labs. If they are not willing to sign, a release will be obtained from each relevant patient. The Clinical Director will conduct monthly chart audits to ensure compliance. The TQM Director will be responsible for oversight. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records the facility failed to document efforts towards informing clients of their rights in nineteen of nineteen client records.
Findings:
Nineteen client records were reviewed on February 4-5, 2009. Documentation of the client's right to inspect his/her own record was required in nineteen client records.
The facility did not document the client' s right to inspect his/her own record in inpatient detoxification client records # 1, 2, 3, 4, and 5.
The facility did not document the client' s right to inspect his/her own record in inpatient residential client records # 1, 2, 3, 4, 5, 6, 7 and 8.
The facility did not document the client' s right to inspect his/her own record in partial hospitalization client records # 1, 2, 3, 4, 5 and 6
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Plan of Correction
The TQM Director will add to the client rights document the right of the client to inspect his/her own records. The QI Assistant will monitor charts for compliance on a monthly basis. The TQM Director will be responsible for oversight. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of policy regarding aftercare plans and client records, the facility failed to document aftercare plans in two of two client records where required.
Findings:
The policy and procedure manual was reviewed on February 2, 2009. Policy stated that aftercare plans were completed for all types of discharges. Two client records were reviewed on February 4 and 5, 2009. An aftercare plan was required in two client records. The facility failed to document an aftercare plan in client records #4 and 5..
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Plan of Correction
The Clinical Director will revise the Aftercare policy, stating that aftercare plans are required for patients who are not scheduled for an appointment upon discharge. In a meeting, on 4/15/09, the Clinical Director will educate counselors of the need to complete an aftercare plan for all patients who are not scheduled for an appointment upon discharge. The Clinical Director will monitor compliance through monthly chart reviews. The TQM Director will be responsible for oversight. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of 19 client records, the facility failed to document a psychosocial evaluation in six of six client records where required.
Findings:
Nineteen client records were reviewed on February 4 and 5, 2009, of those nineteen records, eight inpatient residential client records were reviewed. Psychosocial evaluations were required in six of eight residential client records. The facility did not document a psychosocial evaluation to include the client ' s assets/strengths, support systems and negative factors in six of six client records, # 1, 2, 3, 5, 6 and 8.
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Plan of Correction
In a meeting on 3/18/09, the Clinical Director will educate counselors about the need to complete all required elements of the psychosocial evaluation, including patients' assets/strengths, support systems and negative factors. The Clinical Director will monitor compliance through monthly chart auditing. The TQM Director will be responsible for oversight. |
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
Base on a review of client records, the facility failed to document a treatment plan update in one of one client records where required.
Findings:
Nineteen client records were reviewed on February 4 and 5, 2009, of those nineteen records, eight inpatient residential client records were reviewed. A treatment plan update was required in one of eight client records where required. The facility failed to document a treatment plan update to include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in client record # 6.
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Plan of Correction
In a meeting on 3/18/2009, the Clinical Director will educate counselors on the need for treatment plan updates to include as assessment of a patient's progress in relationship to the stated goals of the comprehensive treatment plan. The Clinical Director will monitor compliance through monthly chart auditing. The TQM Director will be responsible for oversight. |