INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on February 4, 2019 through February 6, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility failed to ensure that the staff person appointed to the project director position met the appropriate educational requirements prior to being appointed. Employee #1 was hired as the project director on April 16, 2018. The documentation provided indicated that employee #1 has a Master of Architecture and a Bachelor's degree in Architecture. Both degrees are non-qualifying for the position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staffing exemption was approved by DDAP for the employee in question as of February 27, 2019.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to provide documentation that an individual training plan, for the current training year, was either appropriate to the employee's skill level or was not developed at all in 7 of 13 personnel records reviewed.
Employee # 3 was hired as a clinical supervisor on July 1, 2010. The individual training plan, signed by the employee and supervisor on July 26, 2018, failed to list any trainings.
Employee # 5 was hired as a counselor on March 26, 2018. The individual training plan, signed by the employee and supervisor on April 2, 2018, failed to list any trainings.
Employee # 9 was hired as a clinical supervisor on January 4, 2014. The personnel record did not contain an individual training plan for the current training year.
Employee # 10 was hired as a counselor on August 1, 2016. The personnel record did not contain an individual training plan for the current training year.
Employee # 12 was hired as a counselor on November 21, 2016. The personnel record did not contain an individual training plan for the current training year.
Employee # 13 was hired as a counselor on November 28, 2016. The personnel record did not contain an individual training plan for the current training year.
Employee # 15 was hired as a clinical supervisor on August 30, 2005. The individual training plan, signed by the employee and supervisor on November 19, 2018, failed to list any trainings.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new VP of Human Resources was appointed in January of 2019 and is overseeing the overall improvement of the staff development program, which includes reviewing training plans for substance upon submission from staff/managers and holding managers accountable to submit training plans on time.
The Human Resources Generalist will pull all employee files who would be responsible for conducting an Annual Performance Evaluation(managers, directors, VP) job descriptions and add Annual Performance Evaluations as function of their job. The timely completion of Annual Performance Evaluations will become part of the employee (manager, director, VP) Performance Evaluations. The Human Resources Generalist will add a calendar invitation to the manager/director/VP internal calendar 3 months prior to the due date to ensure timely submissions for 90 day and Performance Evaluations. The Human Resources Generalist will review every submission of 90 day Evaluations and Performance Evaluations for 100% accuracy.
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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
The facility failed to ensure that 5 of 19 reviewed employees received the minimum of 6 hours of HIV/AIDS training and/or 4 hours of TB/STD training within the regulatory timeframe.
Employee #9 was hired as a clinical supervisor on January 6, 2014 and was due to have HIV/AIDS training and TB/STD training no later than January 6, 2016. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.
Employee #16 was hired in dining services on November 13, 2016 and was due to have HIV/AIDS training November 16, 2018. There was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #17 was hired as a staff tech on August 15, 2011 and was due to have HIV/AIDS training no later than August 15, 2013. There was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #18 was hired as a staff tech on June 13, 2016 and was due to have HIV/AIDS training and TB/STD training no later than June 13, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.
Employee #19 was hired as a nurse tech on March 5, 2016 and was due to have HIV/AIDS training and TB/STD training no later than March 5, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
A new VP of Human Resources was appointed in January of 2019 and is overseeing the overall improvement of the staff development program, which includes requiring individuals who are out of compliance on required trainings to register prior to returning to work. Staff must attend their scheduled training or will face unpaid leave until the training is obtained. Failure to attend the appropriate trainings could warrant termination.Employees will be required to attend the next training offering.
Based on the DDAP Training Management System there is not an available HIV/AIDS training offering until December 2019. Employees # 9, 16, 17, 18, 19 are required to register. If a training is added to the DDAP Training Management System in the immediate area at a sooner date, these above stated employees will be required to register and attend.
Employees #9, 18 are scheduled to attend the TB/STD training offering on April 2, 2019. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The facility failed to document the completion of 12 clock hours of annual training required for a clinical supervisor for the training year of July 1, 2017 to June 30, 2018 in one applicable personnel record.
Employee #9's file did not contain any completed training hours for the reviewed training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new VP of Human Resources was appointed in January of 2018 and is overseeing the overall improvement of the staff development program, which includes requiring individuals to attend required amount of trainings or face unpaid leave until the requirement is met. Education Coordinator will send quarterly reports to all managers to alert them of their staffs training hours.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document the completion of 25 clock hours of annual training required for counselors for the facility's July 1, 2017 through June 30, 2018 training year in three employee files.
Employee #11's file documented 9.5 hours of annual training for the reviewed training year.
Employee #12's file documented 4 hours of annual training for the reviewed training year..
Employee #13's file documented 12 hours of annual training for the reviewed training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new VP of Human Resources was appointed in January of 2018 and is overseeing the overall improvement of the staff development program, which includes requiring individuals to attend required amount of trainings or face unpaid leave until the requirement is met. Education coordinator to send quarterly reports to all managers to alert them of their staffs training hours.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that all applicable personnel records contained documentation of an annual written individual performance evaluation in four employee records.
Employee # 9 was hired as a clinical supervisor on January 6, 2014. There was no documentation of an annual written individual performance evaluation completed for the 2018 review year.
Employee # 10 was hired as a counselor on August 1, 2016. There was no documentation of an annual written individual performance evaluation completed for the 2018 review year.
Employee # 12 was hired as a counselor on November 21, 2016. There was no documentation of an annual written individual performance evaluation completed for the 2018 review year.
Employee # 13 was hired as a counselor on November 28, 2016. There was no documentation of an annual written individual performance evaluation completed for the 2018 review year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new VP of Human Resources was appointed in January of 2019 and is overseeing the overall improvement of the staff development program, which includes reviewing training plans for substance upon submission from staff/managers and holding managers accountable to submit training plans on time.
The Human Resources Generalist will pull all employee files who would be responsible for conducting an Annual Performance Evaluation(managers, directors, VP) job descriptions and add Annual Performance Evaluations as function of their job. The timely completion of Annual Performance Evaluations will become part of the employee (manager, director, VP) Performance Evaluations. The Human Resources Generalist will add a calendar invitation to the manager/director/VP internal calendar 3 months prior to the due date to ensure timely submissions for 90 day and Performance Evaluations. The Human Resources Generalist will review every submission of 90 day Evaluations and Performance Evaluations for 100% accuracy.
Employees #9,10,11,13 will have the missing performance evaluation put in there HR file by 3/22/2019.
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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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 1 of 14 client records reviewed.
Client #13 was admitted to the inpatient nonhospital level of care on March 19, 2018 and was discharged on April 16, 2018. There was documentation of a family counseling session with three family members present on April 5, 2018, however, there were no consent to release information forms on file for two of the family members prior to the disclosure during the session.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Although the act of the patient agreeing to participate in a family session is passive consent, the release of information policy will be updated by 3/15/19 to include family sessions as an event that requires written consent. Director of QI will include this update in monthly chart audits to monitor compliance.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.
The incident dates and reasons are:
March 13, 2018- ambulance presence requested
May 12, 2018 - ambulance presence requested
July 6, 2018- ambulance presence requested
July 23, 2018- police presence requested
July 25, 2018- police presence requested
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Livengrin's Unusual Incident report policy was updated as of 2/6/19 to include the new reporting requirements.
The Director of Quality Improvement is responsible for on-going incident reporting compliance.
Staff memo was sent out 3/14/2019. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
The facility failed to include documentation of the medical director's countersignature in client records, on functions delegated to the certified registered nurse practitioner in four of five applicable client records.
Client #1 was admitted to the inpatient nonhospital detoxification level of care on February 2, 2019 and was active at the time of the inspection. The physical examination, delegated to the certified registered nurse practitioner, was completed on February 3, 2019; however, the exam documentation did not include a countersignature from the medical director.
Client #3 was admitted to the inpatient nonhospital detoxification level of care on February 2, 2019 and was active at the time of the inspection. The physical examination, delegated to the certified registered nurse practitioner, was completed on February 3, 2019; however, the exam documentation did not include a countersignature from the medical director.
Client #6 was admitted to the inpatient nonhospital detoxification level of care on January 16, 2019 and was discharged on September 10, 2018. The physical examination, delegated to the certified registered nurse practitioner, was completed on January 17, 2019; however, the exam documentation did not include a countersignature from the medical director.
Client #7 was admitted to the inpatient nonhospital detoxification level of care on September 4, 2018 and was discharged on January 21, 2019. The physical examination, delegated to the certified registered nurse practitioner, was completed on September 7, 2018; however, the exam documentation did not include a countersignature from the medical director.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The EMR system will be updated to make the History and Physical Assessment incomplete unless physician signature is added. Physician countersign procedure will be updated and reviewed with NP's and physician by 3/18/19. This expectation will be added to monthly chart reviews to monitor compliance under supervision from Director of Quality.
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715.9(a) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
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Observations
The facility failed to verify the individual's identity, which is to include the name, address and date of birth, prior to the administration of a narcotic agent in one of five applicable client records.
Client # 6 was admitted to the inpatient nonhospital detoxification level of care on January 16, 2019 and was discharged on January 20, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Patient identification procedure will be reviewed with admission and medical staff by 3/15/19 and added to the monthly chart audit procedure to monitor compliance under supervision of Director of Quality.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to ensure that the client signed an informed consent to treat prior to the administration of a narcotic agent in one of five applicable client records.
Client # 1 was admitted to the inpatient nonhospital detoxification level of care on February 2, 2019 and was active at the time of the inspection. The client's initial dose was on February 4, 2019, but there was no informed consent to treat on file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Narcotic informed consent procedure will be reviewed with admission and medical staff by 3/15/19 and added to the monthly chart audit procedure to monitor compliance under supervision of Director of Quality.
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