INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and inspection for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. The inspection was conducted on February 5 - 6, 2015 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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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 the Staffing Requirements Facility Summary Report, the facility failed to provide documentation of HIV/AIDS and TB/STD training to eight program staff that have direct contact with clients.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on February 2-3, 2015. The facility did not provide documentation of the required HIV/AIDS and TB/STD training to eight program staff.
A staff tech was hired on August 27, 2012. The TB/STD training was due to be completed no later than August 27, 2014. The facility failed to provide documentation of TB/STD training as of the date of the licensing inspection.
A staff tech was hired on August 27, 2012. The HIV/AIDS and TB/STD training was due to be completed no later than August 27, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the licensing inspection.
A staff tech was hired on June 4, 2012. The TB/STD training was due to be completed no later than June 4, 2014. The facility failed to provide documentation of TB/STD training as of the date of the licensing inspection.
An intake worker was hired on January 30, 2012. The TB/STD training was due to be completed no later than January 30, 2014. The facility failed to provide documentation of TB/STD training as of the date of the licensing inspection.
A patient care coordinator was hired on June 25, 2012. The HIV/AIDS and TB/STD training was due to be completed no later than June 25, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the licensing inspection.
An assessor was hired on November 8, 2012. The TB/STD training was due to be completed no later than November 8, 2014. The facility failed to provide documentation of TB/STD training as of the date of the licensing inspection.
The director of intake was hired on December 17, 2012. The HIV/AIDS training was due to be completed no later than December 17, 2014. The facility failed to provide documentation of HIV/AIDS training as of the date of the licensing inspection.
A staff tech was hired on March 27, 2012. The HIV/AIDS and TB/STD training was due to be completed no later than March 27, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A list of all staff out of compliance with mandatory trainings will be compiled by the 04/01/2015. Staff who are out of compliance will be required to attend upcoming HIV/AIDS and TB/STD trainings in our area in April and May 2015. This will be monitored and followed up on by the head of the Training Department. The implementation of electronic monitoring of training attendance by ADP will ensure that all staff maintain training compliance. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure that all heaters are permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on February 5, 2015. A portable heater, that was not permanently mounted or installed, was found in Room/Office D106.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Improvement Department & Maintenance will conduct a monthly internal audit check to ensure there are no space heaters present in the facility. Any found to be out of compliance will be followed up on appropriately. |
709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project in one of five client records reviewed.
The findings include:
Five client records requiring documentation of a complete record were reviewed on February 5-6, 2015. The facility failed to document a complete client record in record #21.
Client #21 was admitted on May 16, 2014 and discharged on June 10, 2014. There was no documentation that an aftercare plan and follow-up were completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The requirement for an aftercare plan is an existing policy. Quality and compliance will be monitored with ongoing chart reviews. Livengrin has created a new role as of December 2014, patient care coordinators, to complete all case management for patients. Patient care coordinators are responsible for completing follow up calls to all discharged patients 7 days after discharge through one year after discharge. The presence of follow up call documentation and aftercare plans will be monitored with ongoing chart reviews. Every active chart is audited weekly by a Quality Improvement team member to ensure that all documentation is complete. |
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 an informed and voluntary consent from the client that adhered to 4 Pa. Code 255.5 in one of twenty-one client records reviewed.
The findings included:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Twenty-one client records were reviewed for documentation of an informed and voluntary consent from the client that adhered to 4 Pa. Code 255.5 on February 5-6, 2015.
Client record #19 contained a consent to release information form for a U.S. Probation officer signed and dated on January 14, 2015 that allowed for the release of assessment results, prescribed medications, results of urine drug screens, and discharge plan, exceeding what is permissible under 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new release will be created in the EMR system with the 5 perimeters listed in 255.5 by Quality Assurance Manager by 04/03/2015. Confidentiality will be reviewed in staff training and work groups by clinical supervisors scheduled for June 2015 and yearly thereafter. The appropriate use of releases will be monitored on an ongoing basis by Medical Records staff. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to document in each patient record the patient's initial dose and schedule.
The findings include:
On February 6, 2015, four patient records were reviewed for documentation of the initial medication dosage and patient schedule. The facility failed to document in one of four patient records the initial dose and schedule, specifically in patient record # 3.
Patient # 3 was admitted 12/31/2014. Patient # 3 was prescribed buprenorphine; however, the facility failed to document the patient's initial dose and schedule. In addition, the facility failed to document that the physician determining the initial dose was the same physician who performed patient # 3's examination or document a consult between the prescribing doctor and the doctor that performed the examination.
The findings were reviewed with facility staff during the inspection.
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Plan of Correction
A training of nursing staff was conducted by the Nurse Manager, to insure that the Buprenorphine Data Form is properly scanned into the chart on a timely basis. The Nurse Manager is responsible for ensuring this corrective action is implemented. The presence of the Buprenorphine Data Form will be a measure used in monthly ongoing chart reviews. The issue was that the form was not scanned into the chart, not that the consultation didn't take place. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on the review of client records, the facility failed to provide a complete client record on each individual which includes information relative to the client's involvement with the project in seven of ten client records.
The findings include:
Ten client records were reviewed on February 5-6, 2015. The facility failed to provide a complete client record for records, #10, 11, 12, 13, 14, 15, and 16.
Client #10 was admitted on June 29, 2014 and discharged on July 21, 2014. There was no documentation that an aftercare plan and follow-up were completed.
Client #11 was admitted on May 19, 2014 and discharged on June 13, 2014. There was no documentation that a follow-up was completed.
Client #12 was admitted on November 7, 2014 and discharged on December 3, 2014. There was no documentation that a discharge summary, aftercare plan, and follow-up were completed.
Client #13 was admitted on August 7, 2014 and discharged on September 4, 2014. There was no documentation that an aftercare plan and follow-up were completed.
Client #14 was admitted on July 18, 2014 and discharged on September 5, 2014. There was no documentation that a follow-up was completed.
Client #15 was admitted on March 28, 2014 and discharged on April 22, 2014. There was no documentation that a follow-up was completed.
Client #16 was admitted on August 31, 2014 and discharged on October 1, 2014. There was no documentation that a follow-up was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The requirement for an aftercare plan is an existing policy. Quality and compliance will be monitored with ongoing chart reviews. Livengrin has created a new role as of December 2014, patient care coordinators, to complete all case management for patients. Patient care coordinators are responsible for completing follow up calls to all discharged patients 7 days after discharge through one year after discharge. The presence of follow up call documentation and aftercare plans will be monitored with ongoing chart reviews. Every active chart is audited weekly by a Quality Improvement team member to ensure that all documentation is complete. |