INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring conducted on March 1, 2022 through March 4, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
|
Plan of Correction
|
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
|
Observations
Based on a review of personnel records, the facility failed to document a written semiannual performance evaluation based upon measurable performance standards in one of one applicable counselor assistants reviewed.
Employee # 18 was hired as a counselor assistant on March 8, 2021 and was still in the position at the time of the inspection. There was no semi-annual performance evaluation completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Human Resource Generalist will update review time frames reminders for counseling assistants. Human Resources with work in conjuntion with Director of Residential Services and Director of Outpatient Services to ensure proper evaluations are performed. The staff member in question has been given the appropriate performance evaluation, these will continue to be completed at six onth intervals until the staff member meets the requirements to become a counselor. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training within the regulatory timeframe in one of eight applicable personnel records reviewed.
Employee # 14 was hired as a counselor on February 8, 2021 and was due to have the HIV/AIDS training no later than February 8, 2022. The HIV/AIDS training was not completed until February 23, 2022.
This is a repeat citation from the May 4, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Human Resource department will communcate with appropriate department heads reagarding training due by staff and the training deadline. Department Directors and Managers will ensure staff receive the training in the assigned time frames. Continued noncompliance may lead to disciplinary action. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
On March 2, 2022, at approximately 12:00 PM, there was a broken windowpane in assessment room 1 of the admissions area of the facility.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Replacement glass was ordered prior to the close of the audit, the installation was completed on 04/06/2022. Maintenance staff will perform monthly inspections of the grounds to prevent physical plant issues moving forward. |
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.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of twenty-eight client records reviewed.
Client # 1 was admitted to the inpatient non-hospital detoxification activity on February 26, 2022 and was still active at the time of the inspection. There was evidence of a disclosure to a pharmacy on March 2, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This is a repeat citation from the May 4, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The pharmacy in question is a contracted service provided. To avoid continued citations all patients will be asked to sign a consent form for this pharmacy during the admissions process . Director of Admissions will perform random chart audits to ensure compliance. Client 1 has been discharged from the program, the consent in question was unable to be updated. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on consent to release information forms in two of twenty-eight client records reviewed.
Client # 4 was admitted to the inpatient non-hospital detoxification activity on January 22, 2022 and was discharged on January 27, 2022. The release of information form to a pharmacy was signed and dated by the client and witness on January 22, 2022; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made.
Client # 8 was admitted to the inpatient non-hospital activity on January 27, 2022 and was still active at the time of the inspection. The release of information form to a pharmacy was signed and dated by the client and witness on January 22, 2022; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The employees in question have been reeduated on the proper consent form completion. The Director of Admissions will perform random chart aduits to ensure continued compliance. Clients 4 & 8 have been discharged from the program, the forms in question were unable to be adjusted.
|
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of twenty-eight applicable client records reviewed.
Client #23 was admitted to the outpatient activity on September 28, 2021 and was still active at the time of inspection. The release of information form to a government agency was signed and dated by the client on October 25, 2021; however, the form failed to document the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The employees in question have been reeduated on the proper consent form completion. Client 23 is still active with the program, the consent form has been corrected. The Program Manager will perform random chart aduits to ensure continued compliance. |
709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
|
Observations
Based on a review of client records, the facility failed to document the dated signature of the witness at the same time as the client on release of information forms in three of twenty-eight applicable client records reviewed.
Client #17 was admitted to the partial hospitalization activity on August 20, 2021 and was discharged on September 8, 2021. The release of information form to the funding source was signed by the witness on August 18, 2021; however, the form was not signed by the client until August 19, 2021.
Client #20 was admitted to the partial hospitalization activity on October 27, 2021 and was discharged on November 22, 2021. The release of information form to the funding source was signed by the witness on October 11, 2021; however, the form was not signed by the client until October 27, 2021.
Client #23 was admitted to the outpatient activity on September 28, 2021 and was still active at the time of inspection. The release of information form to the funding source was signed by the witness on September 24, 2021; however, the form was not signed by the client until September 27, 2021
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The employees in question have been reeduated on the proper consent form completion. Client 17 & 20 have already been discharged from the program, we are unable to adjust the forms. Client 23 is still active and the form has been adjusted. The Program Manager will perform random chart aduits to ensure continued compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to document that a copy of a client consent form was offered to the client on release of information forms in three of twenty-eight applicable client records reviewed.
Client # 6 was admitted to the inpatient non-hospital detoxification activity on February 18, 2022 and was discharged on February 22, 2022. The release of information form to the primary care physician was signed by the client and witness on February 18, 2022; however, there was no documentation that a copy of the consent was offered to the client.
Client # 8 was admitted to the inpatient non-hospital activity on January 27, 2022 and was still active at the time of the inspection. The release of information forms to two separate treatment providers were signed by the client and witness on February 2, 2022 and February 10, 2022; however, there was no documentation that a copy of each consent was offered to the client.
Client # 10 was admitted to the inpatient non-hospital activity on February 22, 2022 and was still active at the time of the inspection. The release of information form to the primary care physician was signed by the client and witness on February 18, 2022; however, there was no documentation that a copy of the consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The employees in question have been reeduated on the proper consent form completion. Client 8 has been discharged from the program. Clients 6 and 10 forms have been updated. The Director of Admissions will perform random chart aduits to ensure continued compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project in one of one applicable client record reviewed.
Client #17 was admitted to the partial hospitalization activity on August 20, 2021 and was administratively discharged on September 8, 2021. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The organization has revised it irregular discharge letter and reeducated staff on the proper protocol for patients that are involuntary terminated. The Program Managers will perform random charts audits to ensure compliance. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client record reviewed.
Client #17 was admitted to the partial hospitalization activity on August 20, 2021 and was administratively discharged on September 8, 2021. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The organization has revised it irregular discharge letter and reeducated staff on the proper protocol for patients that are involuntary terminated. The Program Managers will perform random charts audits to ensure compliance. |
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.
|
Observations
Based on a review of the facility's May 2021 through February 2022 unusual incident report logs, the facility failed to file a written unusual incident report with the Department within three business days following an incident requiring the presence of police, fire, or ambulance personnel on the following dates: June 27, 2021, July 3, 2021, August 5, 2021, August 14, 2021, August 17, 2021, September 1, 2021, September 3, 2021, December 9, 2021, December 21, 2021, December 24, 2021, and January 2, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Staff have been reeducated on the allowed time frames of incident reports and reportable events. Department heads will be responsible for ensuring the appropriate reports are submitted by their staff in a timely manner to the compliance department. The VP of Compliance will randomly review reported incidents to ensure continued compliance. |
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.
|
Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in two of twelve applicable patient records reviewed.
Patient # 1 was admitted on February 26, 2022 and was still active at the time of the inspection. There was no documentation, in the record, of an informed, voluntary, written consent before an agent was administered to the patient for detoxification.
Patient # 2 was admitted on February 26, 2022 and was still active at the time of the inspection. There was no documentation, in the record, of an informed, voluntary, written consent before an agent was administered to the patient for detoxification.
These finding were reviewed with facility staff during the licensing process.
|
Plan of Correction
The medical team and nursing staff were reeducated on consent requirements for patients being treated with buprenorphine. Client 1 & 2 have been discharged from the program. Prior to administering Buprenorphine nurses will ensure the signed consent is in the EMR. Director of Detox and/or Charge Nurse will perform random chart audits to ensure continued compliance. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
|
Observations
Based on a review of patient records, the facility failed to document a complete patient record, which is to include follow-up information, in two of six applicable patient records reviewed.
Patient #11 was admitted to the inpatient non-hospital activity on November 19, 2021 and was discharged on December 3, 2021. The record did not document follow-up information at the time of the inspection.
Patient #13 was admitted to the inpatient non-hospital activity on December 16, 2021 and was discharged on January 13, 2022. The record did not document follow-up information at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The appropriate staff have been reeducated on follow up policy and guidelines during supervision. The Director of Outpatient and/or Progran Manager will perform random chart audits to ensure compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every fifteen days in one of three applicable client records reviewed.
Client # 21 was admitted to the inpatient non-hospital activity on June 30, 2021 and was discharged on July 23, 2021. A treatment plan update was completed on July 1, 2021 and an update was due no later than July 16, 2021; however, there was no update completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The appropraite staff we reeducated during clinical supervision the proper completion intervals of treatment plan completion. The Director of Residential services will perform random chart audit to ensure proper compliance. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to a document a complete client record, which is to include follow-up information, in three of four applicable client records.
Client #26 was admitted to the outpatient activity on September 21, 2021 and was discharged on November 29, 2021. There was no follow-up information documented in the record at the time of the inspection.
Client #27 was admitted to the outpatient activity on October 14, 2021 and was discharged on December 3, 2021. There was no follow-up information documented in the record at the time of the inspection.
Client #28 was admitted to the outpatient activity on November 22, 2021 and was discharged on January 14, 2022. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The appropriate staff have been reeducated on follow up policy and guidelines during supervision. The Director of Outpatient and/or Progran Manager will perform random chart audits to ensure compliance. |