INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Buprenorphine Monitoring conducted on March 3, 2020 through March 6, 2020 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor during the first six months of employment in that position in one of one applicable personnel record.Employee # 3 was hired as a clinical supervisor on April 18, 2019. Monthly supervision notes were required from April 2019 through October 2019; however, there was no documentation provided that monthly supervision occurred.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The VP of Clinical Programs who had not been completing documented monthly supervision was separated from employment on December 20, 2019. Documented supervision began in January 2020 and has continued uninterrupted.
All new clinical supervisors will provide the certificate of completion for the DDAP Clinical Supervision Training to Human Resources. The training certificate will be maintained in the employee training file.
New clinical supervisors will be assigned "Clinical Supervision Training" Modules in Relias. Training Modules are titled: Clinical Supervision: Essentials of Reflective Supervision, Clinical Supervision: Overview of Clinical Supervision, Minimizing Vicarious Liability in Clinical Supervision and Supervision Difficulties in Clinical Practice. Expected completion due at 90 day review.
Employee 3 has been assigned the Clinical Supervision Training Modules with expected completion date of 6/30/2020.
New clinical supervisors will receive documented monthly supervision with their immediate supervisor for the first 6 months of obtaining a clinical supervision role. Documentation of minutes will be maintained in the employment file and be tracked by Human Resources.
Failure to meet the requirements will result in corrective action. |
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
Based on the review of personnel records and the Staffing Requirements Facility Summary Report submitted to the Department on February 10, 2020, the facility failed to provide documentation that an individual training plan was developed with input from the employee and their supervisor for the current training year, identified as July 1, 2019 through June 30, 2020, in 10 of 22 personnel records reviewed.Employee # 2 was hired as the Facility Director on January 2, 2019. There was no documentation of an individual training plan for the current training year.Employee # 5 was hired as a counselor on January 1, 2013. The individual training plan, signed by the employee and supervisor on March 2, 2020, was blank and failed to contain a list of any trainings needed.Employee # 14 was hired as a counselor on June 26, 2011. The individual training plan, signed by the employee and supervisor on March 2, 2020, was blank and failed to contain a list of any trainings needed.Employee # 15 was hired as a counselor on November 21, 2016. The individual training plan, signed by the employee and supervisor on December 19, 2019, was blank and failed to contain a list of any trainings needed.Employee # 17 was hired as Director on July 2, 2018. There was no documentation of an individual training plan for the current training year.Employee # 18 was hired as admissions on August 7, 2017. There was no documentation of an individual training plan for the current training year.Employee # 19 was hired as maintenance on August 28, 2018. There was no documentation of an individual training plan for the current training year.Employee # 20 was hired as staff tech on May 20, 2006. There was no documentation of an individual training plan for the current training year.Employee # 21 was hired as staff tech on October 2, 2014. There was no documentation of an individual training plan for the current training year.Employee # 22 was hired as staff tech on April 10, 2016. There was no documentation of an individual training plan for the current training year.This is a repeat citation from the annual licensing renewal inspections previously conducted on March 8, 2017, March 13, 2018, and February 6, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual Training Plans will be completed on an annual basis. Human Resources will create a comprehensive training plan that will be shared with supervisors in June of each year. Supervisors will collaborate with each employee to develop their training plan. Human Resources will ensure that all training plans are completed and returned by June 30th of each year for the following fiscal year.
Training year will follow the fiscal year of July 1 through June 30. All Livengrin Foundation, Inc. employees will receive new training plans by July 01, 2020.
The training plan for Employee 2 has been updated to reflect individualized training.
All missing or incorrect training plans for the staff noted in Observation #0063 have been emailed to the supervisors and managers with due dates for correction no later than 04/30/2020. Personnel Files will be updated with revised training plans by 04/30/2020.
Human Resources will monitor these training plans. Supervisors or managers not in compliance will be subject to corrective action. |
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 the review of the Staffing Requirements Facility Summary Report, submitted to the Department on February 10, 2020, the facility failed to ensure that 7 of 20 applicable employees reviewed received the minimum of 6 hours of HIV/AIDS training and/or the 4 hours of TB/STD training within the regulatory timeframe.Employee # 22 was hired as a staff tech on April 10, 2016 and was due to have HIV/AIDS training and TB/STD training no later than April 10, 2018. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee # 23 was hired as admissions staff on July 16, 2017 and was due to have HIV/AIDS training and TB/STD training no later than July 16, 2019. There was no documentation of the completion of the HIV/AIDS training or TB/STD training as of the date of the inspection.Employee # 24 was hired as admissions staff on August 17, 2015 and was due to have HIV/AIDS training and TB/STD training no later than August 17, 2017. There was no documentation of the completion of the HIV/AIDS training or TB/STD training as of the date of the inspection.Employee # 25 was hired as a senior staff tech on April 12, 2017 and was due to have HIV/AIDS training and TB/STD training no later than April 12, 2019. There was no documentation of the completion of the HIV/AIDS training or TB/STD training as of the date of the inspection.Employee # 26 was hired as a staff tech on October 2, 2016 and was due to have HIV/AIDS training and TB/STD training no later than October 2, 2018. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee # 27 was hired as a staff tech on December 1, 2017 and was due to have HIV/AIDS training and TB/STD training no later than December 1, 2019. There was no documentation of the completion of the HIV/AIDS training or TB/STD training as of the date of the inspection.Employee # 28 was hired as a staff tech on August 15, 2011 and was due to have HIV/AIDS training and TB/STD 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.This is a repeat citation from the annual licensing renewal inspections previously conducted on February 6, 2015, January 22, 2016, March 8, 2017, March 13, 2018, and February 6, 2019.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Human Resources will continue to monitor mandatory training compliance. Livengrin will support Mandatory Communicable Disease Training when possible. In addition, staff will be provided information on external offerings.
Due to the cancellation of DDAP offered trainings, upcoming trainings are no longer listed as available. When the emergency declaration is lifted and DDAP offered trainings are available again, employees listed on Observation #0067 will be expected to attend Mandatory Communicable Disease Trainings within 6 months or be subject to corrective action. Trainings are to be completed no later than 12/31/2020. |
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
Based on the review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility's July 1, 2018 through June 30, 2019 training year in three of eight personnel files reviewed.Employee # 4's personnel file documented 15.5 hours of annual training.Employee # 14's personnel file documented 23.25 hours of annual training.Employee # 15's personnel file documented 12 hours of annual training.This is a repeat citation from the annual licensing renewal inspection previously conducted on February 6, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Livengrin Foundation, Inc. recently launched a Learning Management System powered by Relias Learning. This provides all employees access to hundreds of web-based trainings, which they can attend at their leisure. Human Resources will continue to monitor staff training hours. Staff that do not complete the required training hours will be subject to corrective action by their immediate supervisors and Human Resources. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on March 4, 2020 at approximately 10:00 am, the facility failed to ensure that there was proper ventillation via an exhaust fan or window in two F house bathrooms located in rooms 001 and 203. The exhaust fans were inoperable and each bathroom did not have a window.
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Plan of Correction
Parts for the exhaust fans were ordered during the inspection. Parts were received March 10 and fans were repaired March 11,2020
The Risk Management Committee completes walk through inspections of all the buildings on the property. Behavioral Techs have been provided the checklists for the houses E, F and G. Checklists will be forwarded to the Director of Facilities Maintenance and Quality Improvement Coordinator weekly. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection conducted on March 4, 2020 at approximately 10:00 AM, the facility failed to ensure that the kitchen freezer's temperature was kept at or below 0 degrees Fahrenheit. The temperature was measured at 14 degrees Fahrenheit on March 4, 2020. The temperature was re-measured on March 6, 2020 at approximately 3:00 PM and the reading was 2 degrees Fahrenheit.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Dietary Director of Linton's, Livengrin Foundation, Inc.'s food service provider has been recording the temperature of the freezer every day. Temperatures have consistently been between -2 and -4 degrees. Livengrin's Director of Facility Maintenance has placed a service call to ensure proper working order following the physical plant walk through. The service provider is scheduled April 12.
Should the temperature rise above zero degrees during the daily checks, Dietary Director will communicate immediately to Director of Facilities Maintenance. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the March 2019 through January 2020 fire drill logs, the facility failed to document which exit route was used on each log. Additionally, the facility failed to document whether a fire alarm or smoke detector was operative at the time of the drill on the June 2019 and August 2019 fire drill logs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Uniform fire drill logs have been distributed to all the sites for immediate use. The fire drill logs for all sites include date and time of the drill, the exit route used , the number of people (patients and staff) participating in the drill, the duration of the fire drill, any problems encountered and whether fire alarms or smoke detectors were operative. Director of Facilities Maintenance will address the importance of answering all questions on the form during staff meetings. Fire Drill Logs will be forwarded to the quality department quarterly for review.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedure manual, the project director failed to prepare, annually update and sign the facility's written manual, which delineates the project policies and procedures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CEO, the project director, has signed off on the 2019 policy manual. Moving forward, the CEO will review and sign off on the policy manual at the beginning of each fiscal year. Livengrin Foundation, Inc.'s fiscal year begins July 01 and ends June 30.
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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
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 of 31 client records. Client # 12 was admitted to the inpatient non-hospital level of care on December 17, 2019 and was discharged on January 21, 2019. There was documentation of a family member being notified and brought into a counseling session by another staff member on January 7, 2020; however, there was no consent to release information form on file for the family member.This is a repeat citation from the annual licensing renewal inspections previously conducted on March 13, 2018 and February 6, 2019.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The confidentiality/ privacy practices policy dated 1/3/2020 will be updated to better cover unusual incidents potentially resulting in a privacy breach and distributed to all staff electronically.
Staff members have all been assigned 42 CFR training through Relias, Livengrin's learning management system. All managers will review consent requirements during staff meetings. Consent requirements fact sheets aligned with PA code 255.5 and the required elements of consent have been distributed to managers, supervisors and directors.
Livengrin Foundation, Inc. has notified Mental Health Consultants, Livengrin's EAP provider, regarding this incident. Our insurance company, NMS, has also been notified prior to notification of client 12 of confidentiality breach.
The staff member noted in the progress note listed in Observation #0276 has been assigned and completed Boundaries Training on the Relias Learning Management System. The corrective action plan was developed by the staff member's immediate supervisor.
A Root Cause Analysis Meeting will be scheduled following the lifting of the PA emergency declaration for COVID-19 with an expected completion date of 5/15/2020. Documented Individual interviews with staff members involved began March 13, 2020.
Additionally, Livengrin Foundation, Inc has locked all outside doors in all public areas. All visitors for patients are expected to enter through the Admissions door, sign in and wait for clinical staff to escort them from the waiting area. These changes were made by end of March 6, 2020. During the COVID-19 Emergency Declaration, all visitation on grounds has been stopped.
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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.
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Observations
Based on the review of client records, the facility failed to document the name of a person, agency or organization to whom the disclosure was to be made to on a consent form in 14 of 31 client records.Client # 1 was admitted to the detoxification level of care on March 4, 2020 and was active at the time of the inspection. There were consent to release information forms with specific purposes to a pharmacy, primary care provider and EAP, all signed and dated by the client on January 7, 2020. However, the consent forms failed to include the specific name of the person, agency or organization.Client # 2 was admitted to the detoxification level of care on March 1, 2020 and was active at the time of the inspection. There was a consent to release information form with specific purposes to an EAP signed and dated by the client on March 1, 2020; however, the consent form failed to include the specific name of the person, agency or organization.Client # 4 was admitted to the detoxification level of care on October 25, 2019 and was discharged on October 28, 2019. There were consent to release information forms with specific purposes to a medical provider and a managed care organization, both signed and dated by the client on October 25, 2019. However, the consent forms failed to include the specific name of the person, agency or organization.Client # 5 was admitted to the detoxification level of care on September 28, 2019 and was discharged on October 1, 2019. There were consent to release information forms with specific purposes to a medical provider and a pharmacy, both signed and dated by the client on February 5, 2019. However, the consent forms failed to include the specific name of the person, agency or organization.Client # 8 was admitted to the detoxification level of care on September 6, 2019 and was discharged on September 9, 2019. There was a consent to release information form with specific purposes to a managed care organization signed by a witness; however, the consent form failed to include the specific name of the person, agency or organization.Client # 9 was admitted to the inpatient non-hospital level of care on February 6, 2020 and was active at the time of the inspection. There was a consent to release information form with specific purposes to a managed care organization signed and dated by the client on February 6, 2020; however, the consent form failed to include the specific name of the person, agency or organization.Client # 10 was admitted to the inpatient non-hospital level of care on February 7, 2020 and was active at the time of the inspection. There was a consent to release information form with specific purposes to a managed care organization signed and dated by the client on February 7, 2020; however, the consent form failed to include the specific name of the person, agency or organization.Client # 14 was admitted to the inpatient non-hospital level of care on October 28, 2019 and was discharged on November 6, 2019. There were consent to release information forms with specific purposes to a medical provider and a managed care organization, both signed and dated by the client on October 25, 2019. However, the consent forms failed to include the specific name of the person, agency or organization.Client # 17 was admitted to the inpatient non-hospital level of care on September 9, 2019 and was discharged on October 6, 2019. There was a consent to release information form with specific purposes to a managed care organization signed by the witness; however, the consent forms failed to include the specific name of the person, agency or organization.Client # 18 was admitted to the partial hospitalization level of care on November 6, 2019 and was active at the time of the inspection. There were consent to release information forms with specific purposes to a medical provider and a managed care organization, both signed and dated by the client on October 25, 2019. However, the consent forms failed to include the specific name of the person, agency or organization.Client # 20 was admitted to the partial hospitalization level of care on February 27, 2020 and was active at the time of the inspection. There were consent to release information forms with specific purposes to a managed care organization, a pharmacy, and an EAP, all signed and dated by the client on February 27, 2020. However, the consent forms failed to include the specific name of the person, agency or organization.Client # 22 was admitted to the partial hospitalization level of care on March 26, 2019 and was active at the time of the inspection. There was a consent to release information form with specific purposes to an EAP signed and dated by the client on October 15,2018; however, the consent form failed to include the specific name of the person, agency or organization.Client # 28 was admitted to the outpatient level of care on October 6, 2019 and was discharged on November 4, 2019. There was consent to release information form with specific purposes to a managed care organization signed by a witness; however, the consent form failed to include the specific name of the person, agency or organization.Client # 31 was admitted to the outpatient level of care on March 6, 2019 and was discharged on May 6, 2019. There were consent to release information forms with specific purposes to a medical provider and a pharmacy, both signed and dated by the client on February 5, 2019. However, the consent forms failed to include the specific name of the person, agency or organization.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Admissions Supervisor is checking consent forms completed upon admission for accuracy and completion on a weekly basis. As needed, Admissions Supervisor delegates appropriate follow up action when a consent needs to be completed.
All staff members have been assigned 42 CFR training module in Relias. Quality Improvement Coordinator will organize and conduct a training session for staff members with direct patient contact as to how to complete and sign consent forms with patients.
The Quality Improvement Coordinator has dispersed an Infographic on the requirements of PA Code 255.5 and the required elements of a valid consent. This has been distributed to all staff completing consents with patients.
All deficient consents for active patients have been brought into compliance. |
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.
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Observations
Based on the review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 2 of 31 client records. Additionally, the facility failed to document what specific information was to be disclosed on a consent to release information form in 2 of 31 client records.Client # 15 was admitted to the inpatient non-hospital level of care on January 31, 2020 and was discharged on February 20, 2020. There was a consent to release information form to medical provider signed and dated by the client on March 21, 2019; however, the consent form failed to include the specific information to be disclosed.Client # 16 was admitted to the inpatient- nonhospital level of care on December 3, 2019. There was a consent to release information form to the funding source signed and dated by the client on December 3, 2019, that allowed for the release of clinical progress notes, continuing care plan, discharge summary and urinalysis results, which exceeds the limits established by 4 Pa. Code 255.5.Client # 19 was admitted to the partial hospitalization level of care on February 21, 2020 and was active at the time of the inspection. There was a consent to release information form to medical provider signed and dated by the client on March 21, 2019; however, the consent form failed to include the specific information to be disclosed.Client # 21 was admitted to the partial hospitalization level of care on January 2, 2020 and was discharged on January 21, 2020. The record contained a consent to release information form to the funding source signed and dated by the client on December 3, 2019, that allowed for the release of clinical progress notes, continuing care plan, discharge summary and urinalysis results. Information, which exceeds the limits established by 4 Pa. Code 255.5.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Admissions Supervisor is checking consent forms completed upon admission for accuracy and completion on a weekly basis. As needed, Admissions Supervisor delegates appropriate follow up action when a consent needs to be completed.
All staff members have been assigned 42 CFR training module in Relias. Quality Improvement Coordinator will organize and conduct a training session for staff members with direct patient contact as to how to complete and sign consent forms with patients.
The Quality Improvement Coordinator has dispersed an Infographic on the requirements of PA Code 255.5 and the required elements of a valid consent. This has been distributed to all staff completing consents with patients.
All deficient consents for active patients have been brought into compliance.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on a consent to release information form in 2 of 31 applicable client records.Client # 15 was admitted to the inpatient non-hospital level of care on January 31, 2020 and was discharged on February 20, 2020. There was a consent to release information form to a medical provider signed and dated by the client on March 21, 2019; however, the consent form failed to include the purpose for disclosure.Client # 19 was admitted to the partial hospitalization level of care on February 21, 2020 and was active at the time of the inspection. There was a consent to release information form to a medical provider signed and dated by the client on March 21, 2019; however, the consent form failed to include the purpose for disclosure.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Admissions Supervisor is checking consent forms completed upon admission for accuracy and completion on a weekly basis. As needed, Admissions Supervisor delegates appropriate follow up action when a consent needs to be completed.
All staff members have been assigned 42 CFR training module in Relias. Quality Improvement Coordinator will organize and conduct a training session for staff members with direct patient contact as to how to complete and sign consent forms with patients.
The Quality Improvement Coordinator has dispersed an Infographic on the requirements of PA Code 255.5 and the required elements of a valid consent. This has been distributed to all staff completing consents with patients.
All deficient consents for active patients have been brought into compliance.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to document the date of the client's signature on a consent to release information form in 3 of 31 client records.Client # 8 was admitted to the detoxification level of care on September 6, 2019 and was discharged on September 9, 2019. There was a consent to release information form to a managed care organization signed by a witness; however, the consent form failed to include the date of the client's signature.Client # 17 was admitted to the inpatient non-hospital level of care on September 9, 2019 and was discharged on October 6, 2019. There was a consent to release information form to a managed care organization signed by a witness; however, the consent form failed to include the date of the client's signature.Client # 28 was admitted to the outpatient level of care on October 6, 2019 and was discharged on November 4, 2019. There was a consent to release information form to a managed care organization signed by a witness; however, the consent form failed to include the date of the client's signature.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Admissions Supervisor is checking consent forms completed upon admission for accuracy and completion on a weekly basis. As needed, Admissions Supervisor delegates appropriate follow up action when a consent needs to be completed.
All staff members have been assigned 42 CFR training module in Relias. Quality Improvement Coordinator will organize and conduct a training session for staff members with direct patient contact as to how to complete and sign consent forms with patients.
The Quality Improvement Coordinator has dispersed an Infographic on the requirements of PA Code 255.5 and the required elements of a valid consent. This has been distributed to all staff completing consents with patients.
All deficient consents for active patients have been brought into compliance.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in 5 of 31 client record reviewed.Client # 8 was admitted to the detoxification level of care on September 6, 2019 and was discharged on September 9, 2019Client # 11 was admitted to the inpatient non-hospital level of care on February 3, 2020 and was active at the time of the inspection.Client # 17 was admitted to the inpatient non-hospital level of care on September 9, 2019 and was discharged on October 6, 2019. Client # 22 was admitted to the partial hospitalization level of care on March 26, 2019 and was discharged on April 29, 2019.Client # 28 was admitted to the outpatient level of care on October 6, 2019 and was discharged on November 4, 2019. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clients who are currently active have had civil rights attestations updated and signed as of 4/08/2020.
Civil Rights Consent form has been sent to the Office of Civil Rights for review. Post Emergency Declaration, The Quality Improvement Coordinator will attend staff meetings during the week of May 15th to train all staff on the required consents. During the emergency declaration, a list of all required signed consents has been distributed to the managers, supervisors and directors of all departments.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in 5 of 31 client record reviewed.Client # 8 was admitted to the detoxification level of care on September 6, 2019 and was discharged on September 9, 2019Client # 11 was admitted to the inpatient non-hospital level of care on February 3, 2020 and was active at the time of the inspection.Client # 17 was admitted to the inpatient non-hospital level of care on September 9, 2019 and was discharged on October 6, 2019. Client # 22 was admitted to the partial hospitalization level of care on March 26, 2019 and was discharged on April 29, 2019.Client # 28 was admitted to the outpatient level of care on October 6, 2019 and was discharged on November 4, 2019. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clients who are currently active have had civil rights attestations updated and signed as of 4/08/2020.
Civil Rights Consent form has been sent to the Office of Civil Rights for review. Post Emergency Declaration, The Quality Improvement Coordinator will attend staff meetings the week of May 15th to train all staff on the required consents. During the emergency declaration, a list of all required signed consents has been distributed to the managers, supervisors and directors of all departments.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed that the clients have the right to inspect their own records. That the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client, as well as documenting the reasons for removing sections in the record in 5 of 31 client record reviewed.Client # 8 was admitted to the detoxification level of care on September 6, 2019 and was discharged on September 9, 2019Client # 11 was admitted to the inpatient non-hospital level of care on February 3, 2020 and was active at the time of the inspection.Client # 17 was admitted to the inpatient non-hospital level of care on September 9, 2019 and was discharged on October 6, 2019. Client # 22 was admitted to the partial hospitalization level of care on March 26, 2019 and was discharged on April 29, 2019.Client # 28 was admitted to the outpatient level of care on October 6, 2019 and was discharged on November 4, 2019. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clients who are currently active have had civil rights attestations updated and signed as of 4/08/2020.
Civil Rights Consent form has been sent to the Office of Civil Rights for review. Post Emergency Declaration, The Quality Improvement Coordinator will attend staff meetings the week of May 15th to train all staff on the required consents. During the emergency declaration, a list of all required signed consents has been distributed to the managers, supervisors and directors of all departments.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed that clients have the right to appeal a decision limiting access to their records to the director in 5 of 31 client record reviewed.Client # 8 was admitted to the detoxification level of care on September 6, 2019 and was discharged on September 9, 2019Client # 11 was admitted to the inpatient non-hospital level of care on February 3, 2020 and was active at the time of the inspection.Client # 17 was admitted to the inpatient non-hospital level of care on September 9, 2019 and was discharged on October 6, 2019. Client # 22 was admitted to the partial hospitalization level of care on March 26, 2019 and was discharged on April 29, 2019.Client # 28 was admitted to the outpatient level of care on October 6, 2019 and was discharged on November 4, 2019. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clients who are currently active have had civil rights attestations updated and signed as of 4/08/2020.
Civil Rights Consent form has been sent to the Office of Civil Rights for review. Post Emergency Declaration, The Quality Improvement Coordinator will attend staff meetings the week of May 15th to train all staff on the required consents. During the emergency declaration, a list of all required signed consents has been distributed to the managers, supervisors and directors of all departments.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on the review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in 5 of 31 client record reviewed.Client # 8 was admitted to the detoxification level of care on September 6, 2019 and was discharged on September 9, 2019Client # 11 was admitted to the inpatient non-hospital level of care on February 3, 2020 and was active at the time of the inspection.Client # 17 was admitted to the inpatient non-hospital level of care on September 9, 2019 and was discharged on October 6, 2019. Client # 22 was admitted to the partial hospitalization level of care on March 26, 2019 and was discharged on April 29, 2019.Client # 28 was admitted to the outpatient level of care on October 6, 2019 and was discharged on November 4, 2019. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clients who are currently active have had civil rights attestations updated and signed as of 4/08/2020.
Civil Rights Consent form has been sent to the Office of Civil Rights for review. Post Emergency Declaration, The Quality Improvement Coordinator will attend staff meetings the week of May 15th to train all staff on the required consents. During the emergency declaration, a list of all required signed consents has been distributed to the managers, supervisors and directors of all departments.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed that clients have the right to submit rebuttal data or memoranda to their own records in 5 of 31 client record reviewed.Client # 8 was admitted to the detoxification level of care on September 6, 2019 and was discharged on September 9, 2019Client # 11 was admitted to the inpatient non-hospital level of care on February 3, 2020 and was active at the time of the inspection.Client # 17 was admitted to the inpatient non-hospital level of care on September 9, 2019 and was discharged on October 6, 2019. Client # 22 was admitted to the partial hospitalization level of care on March 26, 2019 and was discharged on April 29, 2019.Client # 28 was admitted to the outpatient level of care on October 6, 2019 and was discharged on November 4, 2019. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Patient Bill of Rights has been reviewed to include the language Clients have the right to inspect their own records, clients have the right to appeal a decision limiting their access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records and Clients have the right to submit a rebuttal data or memoranda to their records.
All clients who are currently active have had civil rights attestations nad patient bill of rights updated and signed as of 4/08/2020.
Civil Rights Consent form has been sent to the Office of Civil Rights for review. Post Emergency Declaration, The Quality Improvement Coordinator will attend staff meetings the week of May 15th to train all staff on the required consents. During the emergency declaration, a list of all required signed consents has been distributed to the managers, supervisors and directors of all departments.
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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.
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Observations
Based on the review of client records, the facility failed to provide documentation that a client was notified, in writing, of the reason for the facility's decision to involuntarily terminate the client from treatment in one of two applicable client records reviewed. Client # 13 was admitted on September 1, 2019 and was administratively discharged on September 16, 2019.The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
Livengrin Foundation, Inc. Medical Records/ Care Coordinators has mailed written notification to the client.
On 04/08/2020, the Director of Residential Services and Program Manager re-trained the staff on documentation requirements, including review of process of for letters. Livengrin Foundation, Inc. relies on the Medical Records/ Care Coordination Department to send letters to patients and outside agencies.
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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
Based on the review of unusual incidents, 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 incident reasons are:March 21, 2019 - Ambulance presence onsiteOctober 26, 2019 - Police presence onsiteJanuary 2, 2020 - Ambulance presence onsiteThis is a repeat citation form the annual licensing renewal inspection previously conducted on February 6, 2019.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Quality Improvement Coordinator has reviewed the Licensing Alert 02-2018 Dated December 24, 2018.
Staff have been received an electronic copy of Livengrin Foundation, Inc.'s Unusual Incident Reporting Policy including 24 hours timeline. Nursing and Admissions staff have been notified to email with MRN, whether ambulance, fire or police have been on property.
No new incidents have occurred.
All incident reports matching the 5 categories that must be reported to DDAP will be reported to DDAP by the Quality Improvement Coordinator.
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709.82(a) 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:
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Observations
Based on the review of client records, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in four of seven applicable client records reviewed. Additionally, the facility failed to document on the individual treament plan if there were long-term goals, the type and frequency of services to be provided and any support services in two of seven applicable client records reviewed.Client # 18 was admitted on November 6, 2019 and was active at the time of the inspection. There was no individual treatment plan documented in the client record as of the date of the inspection.Client # 20 was admitted on February 27, 2020 and was active at the time of the inspection. There was no individual treatment plan documented in the client record as of the date of the inspection.Client # 21 was admitted on January 2, 2020 and was discharged on January 21, 2020. The individual treatment plan was completed on January 15, 2020 and the plan failed to include long-term goals, the type and frequency of services to be provided, and a client signature. There was not any other documentation provided that indicated the plan was developed with the client.Client # 24 was admitted on December 30, 2019 and was discharged on January 24, 2020. The individual treatment plan was completed on December 30, 2019 and the plan failed to include long-term goals, the type and frequency of services to be provided, and a client signature. There was not any other documentation provided that indicated the plan was developed with the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A comprehensive review of documentation protocol and policies regarding treatment plan signatures, due dates, and frequency of services was conducted today, 04/08/20202, by the Director of Residential Services and Program Manager.
Compliance staff will be responsible for ongoing monitoring of chart compliance.
All active client records have been brought into compliance. |
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 the review of client records, the facility failed to provide counseling to a partial hospitalization client on a regular and scheduled basis which is to include individual counseling, at least once a week, in three of six client records reviewed.The facility has a current Department exception request on file which exempts the facility from having to comply with the regulatory requirement of individual sessions at least twice weekly. The exception allows the facility to require 1 individual counseling session per week for partial hospitalization clients.Client # 18 was admitted on November 6, 2019 and was active at the time of the inspection. There have been no individual sessions documented in the client record since December 16, 2019.Client # 21 was admitted on January 2, 2020 and was discharged on January 21, 2020. Documentation of one individual counseling session was not completed for the week of January 5, 2020 through January 11, 2020.Client # 23 was admitted on August 22, 2019 and was discharged on September 27, 2019. Documentation of one individual counseling session was not completed for the week of September 15, 2019 through September 21, 2019.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
One offending staff member has been separated from employment and another has been subject to corrective action as of April 1, 2020.
A comprehensive review of documentation requirements, including individual sessions being documented weekly or case management note regarding client cancellation, and re-training on the regulations for all levels of care was held on April 8, 2020.
Director of Residential and Program Manager will track weekly delivery of service. Compliance staff will continue to monitor chart compliance, including documentation of individual sessions, monthly.
Clinicians found to be repeatedly non-compliant may be subject to corrective action.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of client records, the facility failed to verify the individual's identity, which is to include their name, address and date of birth, prior to the administration of a narcotic agent in two of six applicable client records.Client # 6 was admitted to the detoxification level of care on December 12, 2019 and was discharged on December 17, 2019. The client's first medication dose was on December 14, 2019.Client # 7 was admitted to the detoxification level of care on August 29, 2019 and was discharged on September 1, 2019. The client's first medication dose was on August 29, 2019.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Re-training in the Nursing Department by the Medical Director and Nurse Manager took place 03/09/2020.
Admissions Department was retrained regarding acceptable forms of identification and scanning into Livengrin Foundation, Inc.'s EHR system, Aura, also took place on 3/09/2020. Admissions Department also handles pre-screen telephone calls and has reviewed the need for photo identification for admission.
The policy has been revised and reviewed with all staff in both the Medical and Admissions Department.
Director of Admissions is reviewing identification of all admissions in the Bensalem location.
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715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to ensure that the narcotic treatment physician determined the patient's initial dose and schedule in five of six applicable records reviewed. At the time of the inspection, the facility did not have, nor have they applied for, a federal exemption to allow Physician Assistants and Certified Registered Nurse Practitioners to make the face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug, or to prescribe methadone or buprenorphine.Client # 1 was admitted to the detoxification level of care on March 4, 2020 and was active at the time of the inspection. The client's initial dose was on March 4, 2020. The face to face and current dependency was completed by a CRNP on March 4, 2020. The physician did not complete the face to face and current dependency documentation.Client # 2 was admitted to the detoxification level of care on March 1, 2020 and was active at the time of the inspection. The client's initial dose was on March 2, 2020. The face to face and current dependency was completed by a CRNP on March 2, 2020. The physician did not complete the face to face and current dependency documentation.Client # 3 was admitted to the detoxification level of care on March 1, 2020 and was active at the time of the inspection. The client's initial dose was on March 2, 2020. The face to face and current dependency was completed by a CRNP on March 2, 2020. The physician did not complete the face to face and current dependency documentation.Client # 5 was admitted to the detoxification level of care on September 28, 2019 and discharged on October 1, 2019. The client's initial dose was on September 29, 2019. The face to face and current dependency was completed by a CRNP on September 28, 2019. The physician did not complete the face to face and current dependency documentation.Client # 6 was admitted to the detoxification level of care on December 12, 2019 and discharged on December 17, 2019. The client's initial dose was on December 14, 2019. The face to face and current dependency was completed by a CRNP on December 13, 2019. The physician did not complete the face to face and current dependency documentation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Livengrin Foundation, Inc. has been in-process with the DEA for an institutional license since March, 2019. Integrated Security Systems will be on site April 14 and 15 to update security in Livengrin's medication room to be DEA compliant. Institutional DEA licensing is expected to be completed 06/30/2020.
In preparation for SAMHSA licensing, Livengrin Foundation, Inc. has hired a pharmacy consultant and he has already begun work with Livengrin Foundation, Inc.'s medication policies. SAMHSA licensing is expected to be complete by 06/30/2021.
Livengrin Foundation, Inc. has requested a waiver for 715.9 (a)(4). Expected turn around time is 30 business days or May 25, 2020.
Should the waiver be denied, Dr. Eileen Bonner, a current board member, and Agency Doctors will be employed to meet with patients in the detoxification level of care with Livengrin Foundation, Inc. |
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 the review of client records, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in one of seven client records reviewed. Additionally, facility failed to follow the facility's policy and procedures for when the completion of the individual treatment and rehabilitation plan is to be completed in four of seven client records.Client # 13 was admitted on September 1, 2019 and was discharged on September 16. The facility ' s policy and procedure manual stated that the individual treatment plan must be developed within seven days from the date of admission; however, the treatment plan was not developed until September 16, 2019.Client # 14 was admitted on October 28, 2019 and was discharged on November 6, 2019. The facility ' s policy and procedure manual stated that the individual treatment plan must be developed within seven days from the date of admission; however, the treatment plan was not developed until November 6, 2019.Client # 15 was admitted on January 31, 2020 and was discharged on February 20, 2020. The facility ' s policy and procedure manual stated that the individual treatment plan must be developed within seven days from the date of admission; however, the treatment plan was not developed until February 10, 2020.Client # 16 was admitted on December 3, 2019 and was discharged on January 2, 2020. The individual treatment plan was completed on December 12, 2019 and the plan failed to include the client ' s signature. There was not any other documentation provided that indicated the plan was developed with the client.Client # 17 was admitted on September 9, 2019 and was discharged on October 6, 2019. The facility ' s policy and procedure manual stated that the individual treatment plan must be developed within seven days from the date of admission; however, the treatment plan was not developed until September 26, 2019.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
A comprehensive review of documentation protocol and policies regarding treatment plan elements including but not limited to time frames has been conducted today, 04/08/2020, by the Director of Residential Services and Program Manager.
The Director of Residential and Program Manager will pull embedded Aura reports titled Patients with Expiring Treatment Plans and Patients without an Active Treatment Plan weekly.
Clinicians who are repeatedly not in compliance may be subject to corrective action.
The Quality Improvement Coordinator will monitor chart compliance monthly and offer continued training on Livengrin's treatment planning policy and timelines as necessary. |
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 the review of client records, the facility failed to properly document the type of services the client was to receive and the frequency of those services on the client's individual treatment plan in three of seven client records reviewed. Client # 12 was admitted on December 17, 2019 and was discharged on January 21, 2020. The individual treatment plan was dated December 18, 2019.Client # 16 was admitted on December 3, 2019 2020 and was discharged on January 2, 2020. The individual treatment plan was dated December 12, 2019.Client # 17 was admitted on September 9, 2019 and was discharged on October 6, 2019. The individual treatment plan was dated September 26, 2019.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
A comprehensive review of documentation protocol and policies regarding treatment plan elements including but not limited to time frames has been conducted on 04/08/2020 by the Director of Residential Services and Program Manager.
All active client charts have been brought into compliance.
Quality Improvement Coordinator will continue to monitor chart compliance monthly and relay findings to the Director of Residential Services and Program Manager. Findings will be discussed during weekly staff meetings and supervision.
Clinicians found to be repeatedly non-compliant may be subject to corrective action.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 the review of client records, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in four of seven applicable client records reviewed. Additionally, the facility failed to document the long-term goals, the types of services and the frequency of services the client was to receive and/or a list of supportive services on the client's individual treatment plan in two of seven applicable client records reviewed.Client # 25 was admitted on September 27, 2019 and was active at the time of the inspection. The individual treatment plan was completed on October 16, 2019 and the plan was missing long term goals, the type and frequency of services to be provided, any supportive services, and a client signature. There was not any other documentation provided that indicated the plan was developed with the client.Client # 26 was admitted on January 24, 2020 and was active at the time of the inspection. The individual treatment plan was completed on February 10, 2020 and the plan failed to include the client signature. There was not any other documentation provided that indicated the plan was developed with the client.Client # 27 was admitted on January 22, 2020 and was active at the time of the inspection. There was no individual treatment plan documented in the client record as of the date of the inspection.Client # 28 was admitted on October 6, 2019 and was discharged on November 4, 2019. The individual treatment plan was completed on October 6, 2019 and the plan was missing the type and frequency of services to be provided.Client # 30 was admitted on September 9, 2019 and was discharge on October 29, 2019. There was no individual treatment plan documented in the client record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Livengrin Foundation, Inc has separated from employment with one of the offending clinicians and a corrective action plan has taken place on Wednesday April 1, 2020 with the remaining clinician.
A comprehensive review of documentation protocol and policies regarding treatment plan signatures, due dates and frequency of services has been conducted today by the Director of Residential Services and Program Manager.
Compliance staff will be responsible for ongoing monitoring of chart compliance.
All treatment plans of active patients have been brought up to compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to provide treatment plan updates within the regulatory timeframe in one of one applicable client records reviewed.Client # 25 was admitted on September 27, 2019 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 16, 2019 with an update due no later than December 16, 2019; however, there was no update completed as of the date of the inspectionThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Livengrin Foundation, Inc. has separated employment with one of the offending clinicians and a corrective action has taken place on Wednesday April 1, 2020 with the remaining clinician.
A comprehensive review of documentation protocol and policies regarding treatment plan signatures, due dates and frequency of services has been conducted on 04/08/2020 by the Director of Residential Services and Program Manager.
Active client treatment plan update has been completed.
Director of Residential Services and Program Manager will use Aura embedded reports, titled Patients with Expiring Treatment Plans and Patients without Active Treatment Plans, to monitor weekly
The Quality Improvement Coordinator will continue to monitor chart compliance monthly and relay the findings to the Director of Residential Services and Program Manager. These findings will be addressed during weekly supervision and staff meetings.
Clinicians found to be repeatedly non compliant may be subject to corrective action.
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