INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10, 2011 through February 11, 2011 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 April 12, 2011.
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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, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Sixteen personnel records were reviewed on February 7, 2011 through February 9, 2011. There was no documentation of HIV/AIDS or TB/STD training in three employee records. Of the three, two was to have HIV/AIDS and TB/STD training within the first year of employment and the rest was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #8, a counselor, was hired August 29, 2009 and was required to have HIV/AIDS & TB/STD training by August 29, 2010. There was no documentation of HIV/AIDS training in the employee's record as of February 9, 2011.
Employee #14, a counselor assistant, was hired October 18, 2009 and was required to have HIV/AIDS & TB/STD training by October 18, 2010. There was no documentation of TB/STD training in the employee's record as of February 9, 2011.
Employee #16, a driver, was hired March 17, 2008 and was required to have HIV/AIDS & TB/STD training by March 17, 2010. There was no documentation of TB/STD training in the employee's record as of February 9, 2011.
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Plan of Correction
Supervisors were informed of the three staff who were out of compliance with mandatory trainings. HIV/AIDS Training will be offered on 4/27/11 and TB/STDs Training will be offered on 5/10/11. These training will be mandatory for staff who are out of compliance. All supervisors were reminded, by email, by the Director, Total Quality Management, of the requirements for mandatory trainings. Compliance will be monitored by the Director, Total Quality Management, on a monthly basis, by reviewing the Staff Training List for HIV/AIDS and TB/STDs. This list will also be forwarded to all supervisors on a monthly basis. Oversight will be provided by the Clinical Director. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure and document that the project director completed at least 12 hours of training for the July 1, 2009 through June 3, 2010 training year in one of two personnel record.
The findings include:
Personnel records were reviewed on February 7, 2011 through February 9, 2011. The Project Director, employee # 1's personnel record was reviewed to ensure that 12 hours of training had been completed and documented for the July 1, 2009 through June 3, 2010 training year.
Employee #1 was hired October 26, 1987 and was required to have obtained 12 hours of training for the July 1, 2009 through June 30, 2010 training year. Employee #1's personnel record only contained 9 documented hours of training for July 1, 2009 through June 30, 2010 training year.
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Plan of Correction
The Director, Total Quality Management, will remind the Project Director of the need to obtain twelve training hours for each training year. The Director, Total Quality Management, will monitor compliance on a monthly basis. If compliance has not been met, the Director, Total Quality Management will review the requirement with the Project Director, on a monthly basis, until the requirement has been met. |
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 observation during a physical plant inspection and an interview with the maintenance supervisor, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on February 10, 2011 at approximately 9:47 AM, it was observed at that time that one of the outside dumpsters located at the back parking lot was only partially covered with lids.
An interview with the maintenance supervisor conducted on February 10, 2011 confirmed that the dumpster was only partially covered with lids at the time of the physical plant inspection.
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Plan of Correction
The Director, Facilities Management reminded the Nutritional Services Manager, on 2/15/11, of the need for all dumpsters to be fully covered at all times. In a meeting, on 2/17/11, the Nutritional Services Manager, reminded all Nutritional Services Staff that all dumpsters need to be fully covered at all times. The Director, Facilities Management will monitor compliance at least on a weekly basis. The Nutritional Services Manager will be informed of any dumpster that is out of compliance. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observations on February 10, 2011 and an interview with the maintenance supervisor, the facility failed to ensure that the hot water temperature did not exceed 120 F in 29 of 43 bathrooms where temperatures were taken.
The findings include:
A physical plant inspection was conducted on February 10, 2011. On February 10, 2011 temperatures for sinks in 4 male detox unit rooms, 4 female detox unit rooms, 22 residential client rooms, and 1 unisex residential restroom were taken. Also, on February 10, 2011 temperatures for sinks in 5 unisex public restrooms, 1 male public restroom, 1 female public restroom, 1 male staff restroom, and 1 female staff restroom were taken. The facility failed to maintain water temperatures in accordance with the regulation in the following locations:
The bathroom sink in male detox unit room # 106 on the first floor in the male's detox wing had a water temperature reading of 130 F.
The bathroom sink in male detox unit room # 108 on the first floor in the male's detox wing had a water temperature reading of 138 F.
The bathroom sink in the male detox unit room # 105 on the first floor in the male's detox wing had a water temperature reading of 130 F.
The bathroom sink in the male detox unit room # 107 on the first floor in the male's detox wing water had a water temperature reading of 140 F.
The bathroom sink in the female detox unit room # 101 on the first floor in the female's detox wing water had a water temperature reading of 143 F.
The bathroom sink in the female detox unit # 100 on the first floor in the female's detox wing had a water temperature reading of 130 F.
The bathroom sink in the female detox unit # 102 on the first floor in the female's detox wing had a water temperature reading of 138 F.
The bathroom sink in the female detox unit # 104 on the first floor in the female's detox wing had a water temperature reading of 131 F.
The bathroom sink in the male residential client room # 109 on the first floor in the male's detox wing water temperature had a temperature reading of 142 F.
The bathroom sink in the male residential client room # 110 on the first floor in the male's residential wing had a water temperature reading of 138 F.
The bathroom sink in the male residential client room # 113 on the first floor in the male's residential wing had a water temperature reading of 138 F.
The bathroom sink in the male residential client room # 112 on the first floor in the male's residential wing had a water temperature reading of 139 F.
The bathroom sink in the male residential client room # 115 on the first floor in the male's residential wing had a water temperature reading of 139 F.
The bathroom sink in the Male residential client room # 116 on the first floor in the male's residential wing had a water temperature reading of 139 F.
The bathroom sink in the male residential client room # 118 on the first floor in the male's residential wing had a water temperature reading of 138 F.
The bathroom sink in the male residential client room # 121 on the first floor in the male's residential wing had a water temperature reading of 130 F.
The bathroom sink in the Male residential client room # 120 on the first floor in the male ' s residential wing had a water temperature reading of 130 F.
The bathroom sink in the female residential client room # 197 on the second floor in the female's residential wing had a water temperature of 140 F.
The bathroom sink in the female residential client room # 199 on the second floor in the female's residential wing had a water temperature readingof 130 F.
The bathroom sink in the female residential client room # 200 on the second floor in the female's residential wing had a water temperature reading of 140 F.
The bathroom sink in the female residential client room # 198 on the second floor in the female's residential wing had a water temperature reading of 138 F.
The bathroom sink in the female residential client room # 204 on the second floor in the female's residential wing had a water temperature reading of 126 F.
The bathroom sink in the unisex public restroom on the second floor in the main building had a water temperature reading of 138 F.
The bathroom sink in the male's public restroom on the first floor in the female's detox wing had a water temperature reading of 140 F.
The bathroom sink in the female's public restroom on the first floor in the female's detox wing had a water temperature reading of 140 F.
The bathroom sink in the male's staff restroom on the first floor in the Admission Department had a water temperature reading of 140 F.
The bathroom sink in the female's staff restroom on the first floor in the Admission Department had a water temperature reading of 141 F.
The bathroom sink in the unisex public restroom on the second floor in Building 500 had a water temperature reading of 150 F.
The bathroom sink in the unisex residential restroom on the second floor in Building 500 had a water temperature reading of 150 F.
An interview with the maintenance supervisor conducted on February 10, 2011 confirmed that the water temperatures for the areas specified did exceed the water temperature of 120 F.
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Plan of Correction
On 2/11/11, the Director, Facilities Management, adjusted the water temperature to 120 F. By 3/31/11, the Director, Total Quality Management, will add temperature monitoring to all Risk Management Checklists. Risk Management inspections are conducted on a monthly basis for all areas of the facility. The results are sent immediately to the Director, Facilities Management and to the Director, Total Quality Management. If a temperature is out of compliance, the Director, Facilities Management will ensure that the correction is made on the same day as the receipt of the checklist. Oversight will be provided by the Director, Total Quality Management. |
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 and an interview with Director, the facility failed to document psychosocial evaluations to include an assessment of the client's composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude toward treatment and/or the counselor's conclusions/impressions, attitude towards treatment and the counselor conclusions/impressions in two of two client records reviewed.
The findings include:
Client records were reviewed on February 10, 2011 through February 11, 2011. Two partial hospitalization client records requiring psychosocial evaluations were reviewed, specifically, records #13 and 14.
The facility failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions in client records #13 and 14.
The Director confirmed the findings.
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Plan of Correction
The Director, Total Quality Management will ensure that Livengrin's Psychosocial Evaluation will be revised to include all required elements The revision will occur by 3/25/11. Compliance will be monitored by the Clinical Director. The Program Manager will be informed of the revision by 3/25/11. In a meeting, on 3/31/11, the Program Manager will inform all counselors of the revision. The Program Manager will randomly review patient charts to ensure compliance. Oversight will be provided by the Clinical Director. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 and an interview with facility staff, the facility failed to document the type and frequency of treatment and rehabilitation services in two of two partial hospitalization client records reviewed.
The findings include:
Client records were reviewed on February 10, 2011 through February 11, 2011. Two partial hospitalization client records requiring individualized comprehensive treatment plans were reviewed, specifically, records #13 and 14. The facility failed to document the type and frequency of treatment and rehabilitation services in Client records # 13 & 14. In addition the treatment plan in client record #14, was completed prior to the completion of the Psychosocial Evaluation.
Client #13 was admitted on 10/25/10. The comprehensive treatment plan was completed on 11/8/10, however, the facility failed to document the type and frequency of treatment and rehabilitation services.
Client #14 was admitted on 11/12/10. The comprehensive treatment plan was completed on 11/17/10, however, the facility failed to document the type and frequency of treatment and rehabilitation services. In addition, the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 11/18/10.
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Plan of Correction
In a meeting, on 3/31/11, the Program Manager will remind all counselors of the need to include type and frequency of services in all Treatment Plans. The Program Manager will also remind all counselors that the Psychosocial Evaluation needs to be completed prior to the Treatment Plan. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Clinical Director. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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 and an interview with facility staff, the facility failed to document the proposed types of support services in two of two partial hospitalization client records reviewed.
The findings include:
Client records were reviewed on February 10, 2011 through February 11, 2011. Two partial hospitalization client records requiring individualized comprehensive treatment plans were reviewed, specifically, records #13 and 14. The facility failed to document the proposed types of support services in Client records # 13 & 14. In addition the treatment plan in client record #14, was completed prior to the completion of the Psychosocial Evaluation.
Client #13 was admitted on 10/25/10. The comprehensive treatment plan was completed on 11/8/10, however, the facility failed to document the proposed types of support services.
Client #14 was admitted on 11/12/10. The comprehensive treatment plan was completed on 11/17/10, however, the facility failed to document the proposed types of support services. In addition, the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 11/18/10.
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Plan of Correction
In a meeting, on 3/31/11, the Program Manager will remind all Counselors of the need to include proposed types of support services in all Treatment Plans. The Program Manager will also remind all Counselors that Psychosocial Evaluations must be completed prior to the Treatment Plan. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Clinical Director. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in two of the four records reviewed in the partial hospitalization activity.
The findings include:
Client records were reviewed on February 10, 2011 through February 11, 2011. Four partial hospitalization client records were reviewed for documentation of individual counseling at least twice weekly. Two of four records reviewed, specifically #s 13 & 14, did not contain documentation of individual counseling at least twice weekly.
Client # 13 was admitted on October 25, 2010 and discharged on December 2, 2010. The client record lacked documentation of two individual sessions per week. The facility's record of service and progress notes documented the following:
For the week of 10/25/10, one individual session was documented on 10/26/10. For the week of 11/2/10, one individual session was documented on 11/2/10. For the week of 11/8/10, no individual sessions were documented. For the week of 11/15/10, one individual sessions was documented on 11/18/11. For the week of 11/22/11, no individual sessions were documented. For the week of 11/29/10, no individual sessions were documented. as
Client # 14 was admitted on November 12, 2010 and discharged on November 29, 2010. The client record lacked documentation of two individual sessions per week. The facility's record of service and progress notes documented the following:
For the week of 11/22/10 no individual sessions were documented.
The facility staff confirmed that the records for clients # 13 & 14 lacked documentation of individual counseling at least twice weekly.
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Plan of Correction
In a meeting, on 3/31/11, the Program Manager will remind all Counselors of the need to complete two individual Seesions per week, for all Partial patients. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Clinical Director. |
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 a review of the facility's policy and procedure regarding client confidentiality, and an interview with the quality assurance manager, the facility failed to develop a written policy and procedure by the project director that complies with 4 Pa. Code subsection 255.5 (a) (1).
The findings include:
The facility's policy and procedure on client confidentiality was reviewed on February 07, 2011 through February 11, 2011.
The facility policy titled: "Confidentiality, revised on February 1, 2006" stated: "As of 4/1/03, HIPPA regulations require that requests for revocation of consents must be in writing".
An interview with quality assurance manger on February 8, 2011 confirmed that the facility followed the HIPPA regulations and that all consent to release information forms include the statement that revocations of consent must be in writing. The quality assurance manager also confirmed that the facility's policy did not conform with 4 Pa. Code subsection 255.5 (a) (1)
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Plan of Correction
The Director, Total Quality Management will revise the Confidentiality Policy by 3/31/11. The revised policy will state that the patient has the right to revoke consents verbally or in writing. The Clinical Director will ensure that the policy is revised by 3/31/11. The revised policy will be distributed to all staff. All staff will need to complete a sign-off sheet, indicating that they have read and understood the revised policy. The Program Manager and the Director of Admissions will randomly monitor patient charts, on a monthly basis, to ensure compliance. All current patients will be required to sign revised consents, by 3/31/11. |
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 ensure that the client is notified of his/her right to revoke client consents to release information verbally or in writing in fourteen of fourteen records reviewed.
The findings include:
On February 10, 2011 through February 11, 2011, fourteen client records were reviewed for consent to release information forms. The consent to release form had verbiage that only gave the client the right to revoke in writing in client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 1 3 and 14. "I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it by notifying the Director of Medical Records or the Outpatient Program Manager in writing".
Also, the facility's policy and procedure regarding client confidentiality was reviewed on February 07, 2011 through February 11, 2011. The facility policy on client confidentiality revised on February 1, 2006 stated that "As of 4/1/03, HIPPA regulations require that request for revocation of consents must be in writing". An interview with facility staff revealed that the facility followed the HIPPA regulations and that all consent to release information forms include the statement that revocations of consent must be in writing.
Client record #1 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1 Consent to release for family member, dated 9/23/10
2. Consent to release for (agency or person not documented), dated 9/23/10
3. Consent to release for insurance company, dated 9/23/10
Client record #2 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for medical practitioner, dated 10/11/10
2. Consent to release for manage care organization company, dated 10/11/10
3. Consent to release for insurance company, dated 10/11/10
4. Consent to release for insurance company, dated 10/11/10
Client record #3 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for family member company, dated 2/9/11
2. Consent to release for insurance company, dated 2/9/11
3. Consent to release for medical practitioner, dated 2/9/11
Client record #4 contained the following consents to release information that did not allow for the verbal revocation of the consents:
2. Consent to release for family member, dated 2/10/11
3. Consent to release for PCP, dated 2/10/11
Client record #5 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for employer/FMLA, dated 1/24/11
2. Consent to release for medical practitioner, dated 1/20/11
3. Consent to release for managed care organization, dated 1/20/11
4. Consent to release for emergency contact, dated 1/20/11
Client record #6 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for employee assistance program, dated 1/22/11
2. Consent to release for medical practitioner, dated 1/22/11
3. Consent to release for managed care organization, dated 1/22/11
4. Consent to release for emergency contact, dated 1/22/11
Client record #7 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for emergency contact, dated 1/24/11
2. Consent to release for medical practitioner, dated 1/24/11
3. Consent to release for managed care organization, dated 1/24/11
4. Consent to release for emergency contact, dated 1/28/11
Client record #8 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for medical practitioner, dated 9/20/10
2. Consent to release for managed care organization, dated 9/20/10
3. Consent to release for emergency contact, dated 9/20/10
Client record #9 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for emergency contact, dated 9/23/10
2. Consent to release for medical practitioner, dated 9/23/10
3. Consent to release for managed care organization, dated 9/23/11
In addition, client record #9 contained documentation indicating that the facility conducted meetings with a family member on 10/3/10 & 10/6/10 without a consent to release information, and that the facility made a telephone call to an agency pertaining to the client without a consent to release information for that agency.
Client record #10 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for medical practitioner, dated 10/7/10
2. Consent to release for emergency contact, dated 10/7/10
In addition, client record #10 contained documentation indicating that the facility held a meeting with a family member on 10/16/10 without a consent to release information, and the facility sent two letters on 11/11/10 to an insurance company and a fax on 10/26/10 to an agency did and did not have consents to release information.
Client record #11 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for medical practitioner, dated 2/6/11
2. Consent to release for manage care organization, dated 2/6/11
3. Consent to release for emergency contact, dated 2/6/11
Client record #12 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for medical practitioner, dated 1/19/11
2. Consent to release for manage care organization, dated 1/19/11
3. Consent to release for emergency contact, dated 1/19/11
Client record #13 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for medical practitioner, dated 10/25/10
2. Consent to release for manage care organization, dated 10/25/10
3. Consent to release for emergency contact, dated 10/25/10
4. Consent to release for claims examiner, dated 10/25/10
Client record #14 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for medical practitioner, dated 11/12/10
2. Consent to release for manage care organization, dated 11/12/10
3. Consent to release for emergency contact, dated 11/12/10.
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Plan of Correction
The Director, Total Quality Management will revise all relavent consents by 3/25/11. Revised consents will state that the patient has the right to revoke consents verbally or in writing. The Clinical Director will ensure that the revisions occur by 3/25/11. The revised consents will be sent to the Information Technology Department by 3/25/11. The Department will remove the incorrect consents and add the revised consents to the electronic record by 3/28/11. The Director, Total Quality Management will inform the Program Manager by 3/28/11, by email, that the revised consents are contained in the electronic record. The Program Manager will inform all Counselors, by email, on 3/28/11, that revisions have been made to consents. All future patients, beginning with 3/28/11, will be required to read and sign the revised consents. All current patients will be required to read and sign revised consents by 3/31/11. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be probided by the Clinical Director. |
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 client records and an interview with the Director,the facility failed to document psychosocial evaluations to include an assessment of the client's composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude toward treatment and/or the counselor's conclusions/impressions, attitude towards treatment and the counselor conclusions/impressions in two of two client records reviewed.
The findings include:
Client records were reviewed on February 10, 2011 through February 11, 2011. Six client records for residential treatment and rehabilitation requiring psychosocial evaluations were reviewed, specifically, records # 5, 6, 7, 8, 9 and 10.
The facility failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions in client records # 5, 6, 7, 8, 9 and 10.
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Plan of Correction
The Director, Total Quality Management will ensure that the Psychosocial Evaluation will be revised to include all required elements. The revision will occur by 3/25/11. Compliance will be monitored by the Clinical Director. In a meeting, on 3/31/11, the Program Manager will inform all Counselors of the revision of the Psychosocial Evaluation. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Clinical Director. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to develop an individualized treatment and rehabilitation plan with the client in six of six residential treatment and rehabilitation client records reviewed.
The findings include:
Client records were reviewed on February 10, 2011 through February 11, 2011. Six residential treatment and rehabilitation client records requiring individualized comprehensive treatment plans were reviewed, specifically, records 5, 6, 7, 8, 9 and 10. The facility failed to develop an individualized treatment and rehabilitation plan with the client in six of six records reviewed, specifically records # 5, 6, 7, 8, 9 and 10.
Client #5 was admitted on 1/24/11. The comprehensive treatment plan was completed on 1/24/11, however the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 1/31/11.
Client #6 was admitted on 1/24/11. The comprehensive treatment plan was completed on 1/24/11, however the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 1/27/11.
Client #7 was admitted on 1/28/11. The comprehensive treatment plan was completed on 2/3/11, however the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 2/4/11.
Client #8 was admitted on 9/23/10. The comprehensive treatment plan was dated 9/24/10, however the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 9/25/10.
Client #9 was admitted on 9/26/10. The comprehensive treatment plan was completed on 9/26/10, however the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 10/2/10.
Client #10 was admitted on 10/10/10. The comprehensive treatment plan was completed on 10/10/10, however the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 10/11/10.
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Plan of Correction
In a meeting, on 3/31/11, the Program Manager will remind all Counselors of the need to complete Treatment Plans for all patients, by the seventh day of treatment. The Program Manager will also remind all Counselors that the Psychosocial Evaluation needs to be completed prior to the Treatment Plan. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Clinical Director. |
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 and an interview with facility staff, the facility failed to document the type and frequency of treatment and rehabilitation services in three of six residential treatment and rehabilitation client records reviewed.
The findings include:
Client records were reviewed on February 10, 2011 through February 11, 2011. Six residential treatment and rehabilitation client records requiring individualized comprehensive treatment plans were reviewed, specifically, records 5, 6, 7, 8, 9 and 10. The facility failed to document the type and frequency of treatment and rehabilitation services in client records,# 5, 7 and 8.
Client #5 was admitted on 1/24/11. The comprehensive treatment plan was completed on 1/24/11, however the facility failed to document the type and frequency of treatment and rehabilitation services. In addition, the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 1/31/11.
Client #7 was admitted on 1/28/11. The comprehensive treatment plan was completed on 2/3/11, however the facility failed to document the type and frequency of treatment and rehabilitation services. In addition, the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 2/4/11.
Client #8 was admitted on 9/23/10. The comprehensive treatment plan was dated 9/24/10, however the facility failed to document the type and frequency of treatment and rehabilitation services. In addition, the comprehensive treatment plan was completed prior to the completion of the Psychosocial Evaluation which was completed on 9/25/10.
Facility staff confirmed the findings.
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Plan of Correction
In a meeting, on 3/31/11, the Program Manager will remind all Counselors of the need to include type and frequency of services in Treatment Plans for all patients. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Clinical Director. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and an interview with facility staff, the facility failed to document an aftercare plan in one of one client records reviewed.
The findings include:
Client records were reviewed on February 10, 2011 through February 11, 2011. One residential and rehabilitation client record requiring an aftercare plan was reviewed, specifically client record #9.
Client #9 was admitted on September 23, 2010 and discharged on October 17, 2010. There was no documentation of an aftercare plan in the client record as of the date of this inspection.
Facility staff confirmed that an aftercare plan had not been documented in client record #9.
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Plan of Correction
In a meeting, on 3/31/11, the Program Manager will remind all counselors that Aftercare Plans need to be completed for patients, according to Livengrin's policy. Aftercare Plans are not required for patients who leave treatment AFA or refuse to participate in an Aftercare Plan. Aftercare Plans are not required for patients referred to another facility. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Clinical Director. |
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 a physical plant inspection and an interview with one of the maintenance workers, the maintenance supervisor, and the quality assurance manager the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum capacity of beds to the number of clients.
The findings include:
A physical plant inspection was conducted on February 10, 2011 at approximately 9:30 A.M. and 1:30 P.M. The facility's authorized maximum capacity for Inpatient Non-Hospital beds to the number of clients is 62. At the time of the inspection the total number of beds observed was 64.
1. 3 beds on the first floor in the male's detox wing.
2. 34 beds on the first floor in the male's residential wing.
3. 4 beds on the first floor in Building 500.
4. 4 beds on the second floor in Building 500.
5. 19 beds on the second floor in the female's residential wing.
The facility did not notify the Department of this change in the authorized maximum bed capacity.
An interview with one of the maintenance workers on February 10, 2011 confirmed that the total number of beds was greater than the authorized maximum capacity of beds to the number of clients. Also, an interview on the same day with the maintenance supervisor and quality assurance manager confirmed that the facility did not notify the Department of the change number of beds. In addition, during the interview with the maintenance supervisor and quality assurance manager, the maintenance supervisor and quality assurance manager explained that the facility has more than 62 beds because the facility had placed two extra beds in Building 500 in order to temporarily relocate staff and clients due to inclement weather last month. The maintenance supervisor and quality assurance manager also confirmed that the facility did not take the two extra beds down after the inclement weather and that the beds were able to accommodate two extra clients if needed.
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Plan of Correction
On 2/10/11, the Director, Facilities Management removed the two extra beds located in patient rooms. The Director, Facilities Management will monitor and document the number of beds on a monthly basis, during the Facility Tour, beginning with the tour for 3/11. Compliance will be monitored by the Director, Total Quality Management. |