INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5, 2024 through March 8, 2024 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one employee received the minimum of 4 hours of TB/STD training within the regulatory timeframe.
Employee # 8 was hired as a counselor on January 30, 2023 and was due to have the TB/STD training no later than January 30, 2024. However, the TB/STD training was not completed until February 23, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff member in question has since completed the required training. Moving forward the Compliance Assistant and Senior Vice President will work to get new staff enrolled as quickly as possible to avoid future citations. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection on March 8, 2024, the facility failed to store the utensils in a clean enclosed area after each usage.
The utensils were in an unenclosed area in the dining room at 10:20 a.m., between the breakfast and lunch meals.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Dietary will ensure all utensils are properly covered when patients are not actively being served food. Staff have been educated on the importance of providing sanitary utensils and the Director of Dietary will ensure compliance by completing rounds throughout the day. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drills logs between March 2023 and December 2023, the facility failed to conduct unannounced fire drills at least once a month, as the facility failed to conduct fire drills in each month in buildings E, F, and G. The only fire drills documented in buildings E, F, and G were in June and October 2023.
This is a repeat citation from the March 9, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Maintenance Department has updated fire drill log sheets to include all residential houses, number of exits, exit used, clarification of sounded alarm, and number of participants. The Director will instruct and ensure staff members are located in E, F, and G House during monthly Fire Drills to assure all components are working properly. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two of twenty-eight applicable records reviewed.
Client # 3 was admitted to the Detoxification level of care on December 10, 2023 and was discharged on December 17, 2023. A progress note dated December 16, 2023 indicated that a disclosure of information occurred to another treatment provider; however, the record did not contain an informed and voluntary consent form to the provider.
Client # 14 was admitted to the Residential level of care on November 17, 2023 and was discharged on December 15, 2023. A progress note dated December 14, 2023 indicated that a disclosure of information occurred to another treatment provider; however, the record did not contain an informed and voluntary consent form to the provider.
This is a repeat citation from the March 9, 2023, March 4, 2022, and May 4, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision, The Director or Residential reeducated staff on the importance of confidentiality. Director of Residential will ensure compliance by conducting monthly chart audits |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information disclosed in 18 out of 20 records reviewed.
Client # 1 was admitted to the Detoxification level of care on August 5, 2023 and was transferred to a lower level of care on August 10, 2023. Consent to release information forms to an employer and to the funding source that were signed on August 5, 2023, were missing the specific information to be disclosed.
Client # 2 was admitted to the Detoxification level of care on August 8, 2023 and was discharged on August 11, 2023. A consent to release information form to the funding source that was signed by the client on August 8, 2023, was missing the specific information to be disclosed.
Client # 3 was admitted to the Detoxification level of care on December 10, 2023 and was transferred to a lower level of care on December 17, 2023. A consent to release information form to the funding source that was signed by the client on December 10, 2023, was missing the specific information to be disclosed.
Client # 5 was admitted to the Detoxification level of care on January 11, 2024 and was transferred to a lower level of care on January 16, 2024. A consent to release information form to the funding source that was signed by the client on January 11, 2024, was missing the specific information to be disclosed.
Client # 6 was admitted to the Detoxification level of care on September 8, 2023 and was discharged on September 12, 2023. A consent to release information form to the funding source that was signed by the client on September 8, 2023, was missing the specific information to be disclosed.
Client # 7 was admitted to the Detoxification level of care on February 28, 2024 and was active at the time of the inspection. A consent to release information form to the funding source that was signed by the client on February 28, 2024, was missing the specific information to be disclosed.
Client # 9 was admitted to the Residential level of care on October 25, 2023 and was discharged on November 15, 2023. A consent to release information form to a probation officer that was signed by the client on November 1, 2023, was missing the specific information to be disclosed.
Client # 11 was transferred to the Residential level of care on July 28, 2023 and was transferred to a lower level of care on August 22, 2023. A consent to release information form to the funding source that was signed by the client on July 21, 2023, was missing the specific information to be disclosed.
Client # 13 was transferred to the Residential level of care on February 13, 2024 and was active at the time of the inspection. A consent to release information form to the funding source that was signed by the client on February 5, 2024, was missing the specific information to be disclosed.
Client # 14 was admitted to the Residential level of care on November 17, 2023 and was discharged on December 15, 2023. A consent to release information form to the funding source that was signed by the client on November 17, 2023, was missing the specific information to be disclosed.
Client # 17 was admitted to the Outpatient level of care on October 31, 2023 and was transferred to a higher level of care on January 22, 2024. A consent to release information form to the funding source that was signed by the client on September 5, 2023, was missing the specific information to be disclosed.
Client # 18 was admitted to the Outpatient level of care on June 19, 2023 and was discharged on October 30, 2023. A consent to release information form to the funding source that was signed by the client on May 20, 2023 in a different level of care, was missing the specific information to be disclosed.
Client # 20 was transferred to the Outpatient level of care on September 26, 2023 and was active at the time of the inspection. A consent to release information form to the funding source that was signed by the client on August 16, 2023 in a different level of care, was missing the specific information to be disclosed.
Client # 21 was admitted to the Outpatient level of care on December 12, 2023 and was active at the time of the inspection. A consent to release information form to the funding source that was signed by the client on December 4, 2023 in a different level of care, was missing the specific information to be disclosed.
Client # 22 was transferred to the Partial level of care on October 31, 2023 and discharged on November 21, 2023. A consent to release information form to the funding source that was signed by the client on September 23, 2023 in a different level of care, was missing the specific information to be disclosed.
Client # 25 was transferred to the Partial level of care on August 7, 2023 and discharged on August 30, 2023. A consent to release information form to the funding source that was signed by the client on July 8, 2023 in a different level of care, was missing the specific information to be disclosed.
Client # 26 was admitted to the Partial level of care on November 9, 2023 and transferred to a lower level of care on November 27, 2023. A consent to release information form to the funding source that was signed by the client on November 8, 2023 in a different level of care, was missing the specific information to be disclosed.
Client # 28 was transferred to the Partial level of care on February 23, 2024 and was active at the time of the inspection. A consent to release information form to the funding source that was signed by the client on January 17, 2024 in a different level of care, was missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Vice President and Compliance Specialist have reviewed and updated the language on the consent form in question to specify what information is to be released. Senior Vice President will ensure future revisions on the form include specific information to be released is more specific. Senior Vice President has sent a list of all active patients to the Director of Residential and the Director of Outpatient, the Directors will ensure all active patients sign the new consent form when they meet with their Counselor. Compliance Specialist will follow up weekly with Directors to obtain status update on the progress of getting new consents signed. The Director will review all new patient consent forms to ensure accuracy. |
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 twenty applicable client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in two records reviewed.
Client # 12 was admitted to the Residential level of care on February 20, 2024 and was active at the time of the inspection. A consent to release information form to a family member that was signed by the client on March 4, 2024, was missing the purpose of disclosure.
Client # 20 was transferred to the Outpatient level of care on September 26, 2023 and was active at the time of the inspection. A consent to release information form to a treatment provider that was signed by the client on November 6, 2023, was missing the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The ROI consent form for client #12 has been corrected. Client #20 was not corrected as the client discharged very shortly after the wrap up. During the most recent supervision the Director of Residential and Director of Outpatient re-educated staff of the necessary fields on consent forms. Director of Residential and Director of Outpatient will ensure compliance with proper consent completion during monthly chart audits. |
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 a review of twenty applicable client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.
Client # 3 was admitted to the Detoxification level of care on December 10, 2023 and was transferred to a lower level of care on December 17, 2023. The record contained a consent to release information form to a family member that was dated December 11, 2023; but was not signed by the client. Additionally, the consent to release information form to the funding source was dated December 10, 2023; but was not signed by the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Director of Residential re-educated staff on the required information on consent forms. Counselors also completed a consents training through Relias. The Director of Residential will ensure compliance with proper consent completion during monthly chart audits. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of fourteen records, the facility failed ensure that verbal orders were authenticated in writing by a physician or other medical professional within the regulatory timeframe in six records reviewed.
Client # 3 was admitted to the Detoxification level of care on December 10, 2023 and was transferred to a lower level of care on December 17, 2023. A verbal order was given on December 14, 2023, but was not authenticated in writing until December 18, 2023.
Client # 5 was admitted to the Detoxification level of care on January 11, 2024 and was transferred to a lower level of care on January 16, 2024. A verbal order was given on January 13, 2024 that was not authenticated in writing by an authorized prescriber. An additional verbal order was given on January 13, 2024 that was not authenticated in writing until January 17, 2024.
Client # 6 was admitted to the Detoxification level of care on September 8, 2023 and was discharged on September 12, 2023. A verbal order was given on September 9, 2023, but was not authenticated in writing until September 11, 2023.
Client # 7 was admitted to the Detoxification level of care on February 28, 2024 and was active at the time of the inspection. Verbal orders were given on March 1, 2024, but were not authenticated in writing until March 4, 2024.
Client # 10 was transferred to the Residential level of care on January 16, 2024 and was discharged on January 26, 2024. A verbal order was given on January 19, 2024, but was not authenticated in writing until January 26, 2024.
Client # 14 was admitted to the Residential level of care on November 17, 2023 and was discharged on December 15, 2023. Verbal orders were given on November 17, 2023, but were not authenticated in writing until December 6, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When verbal orders are necessary, the Medical Director will ensure written authentication is completed within the regulatory timeframe. Additionally, Physicians and Medical Professionals authorized by State and Federal Law to prescribe medications have been reeducated on the importance and required compliance of regulatory timeframes. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation by the seventh treatment session, in three of four applicable records reviewed. The facility policy indicates that psychosocial evaluations are to be updated within seven treatment sessions after transferring from one level of care to another within the facility.
Client # 23 was transferred to the Partial level of care on November 20, 2023 and was transferred to a lower level of care on December 4, 2023. The psychosocial evaluation was due to be updated by November 29, 2023; however, the record did not contain an updated psychosocial evaluation.
Client # 25 was transferred to the Partial level of care on August 7, 2023 and discharged on August 30, 2023. The psychosocial evaluation was due to be updated by August 17, 2023; however, the psychosocial evaluation was not until September 14, 2023.
Client # 26 was admitted to the Partial level of care on November 9, 2023 and transferred to a lower level of care on November 27, 2023. The psychosocial evaluation was due to be completed by November 20, 2023; however, the record did not contain an updated psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Director created a new tracking form for counselors to utilize to determine due dates of documentation. Director will monitor compliance through chart audits and continued supervision. |
709.83(a)(4) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(4) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes prior to level of care change, per the facility's policy, in two of five applicable records reviewed.
Client # 22 was transferred to the Partial level of care on October 31, 2023 and discharged on November 21, 2023. The record did not contain documentation of a case consultation note prior to level of care change.
Client # 27 was transferred to the Partial level of care on September 15, 2023 and was transferred to a lower level of care on September 25, 2023. The record did not contain documentation of a case consultation note prior to level of care change.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued supervision. Program Manager has offered additional options for case consultations to be reviewed during supervision sessions. |
709.83(a)(6) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include an aftercare plan, in one of one applicable client records reviewed.
Client # 22 was transferred to the Partial level of care on October 31, 2023 and discharged on November 21, 2023. The client record did not contain documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the importance of proper documentation completion. Additionally, the Program Manager will ensure compliance when completing monthly chart audits. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information within 30 days of discharge, per facility policy, in two of two applicable records reviewed.
Client # 3 was admitted to the Detoxification level of care on December 10, 2023 and was discharged on December 17, 2023. Follow-up was due to be completed by January 17, 2024; however, the follow-up information was not completed until January 25, 2024.
Client # 6 was admitted to the Detoxification level of care on September 8, 2023 and was discharged on September 12, 2023. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Personal Care Coordinators have been educated on the importance of detox discharge follow up's. PCC supervisor will ensure follow up calls are completed by utilizing the 'Task Manager' provided in the EMR. |
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 a review of patient records, the facility failed to ensure that the individual ' s identity was verified during the intake process in three of five records reviewed.
Patient # 3 was admitted to the Detoxification level of care on December 10, 2023 and was transferred to a lower level of care on December 17, 2023. The record did not contain documentation that the patient ' s identity was verified.
Patient # 5 was admitted to the Detoxification level of care on January 11, 2024 and was transferred to a lower level of care on January 16, 2024. The record did not contain documentation that the patient ' s identity was verified.
Client # 14 was admitted to the Residential level of care on November 17, 2023 and was discharged on December 15, 2023. The record did not contain documentation that the patient ' s identity was verified.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were reeducated on the importance of proper identification for individuals who are receiving NTP Substance Abuse Treatment. Admissions Manager will ensure compliance through monthly chart audits. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician determining the initial dose consulted with the narcotic treatment physician who conducted the physical examination before determining the patient ' s dose and schedule in five of five applicable records reviewed.
Patient # 3 was admitted to the Detoxification level of care on December 10, 2023 and was transferred to a lower level of care on December 17, 2023.
Patient # 4 was admitted to the Detoxification level of care on October 18, 2023 and was transferred to a lower level of care on October 25, 2023.
Patient # 5 was admitted to the Detoxification level of care on January 11, 2024 and was transferred to a lower level of care on January 16, 2024.
Patient # 7 was admitted to the Detoxification level of care on February 28, 2024 and was active at the time of the inspection.
Patient # 14 was admitted to the Residential level of care on November 17, 2023 and was discharged on December 15, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In situations where the Narcotic Treatment Physician determining the proper dosage level is not the Narcotic Treatment Physician whom conducted the patient examination, the Medical Director will ensure collaboration has been completed. Staff have been reeducated on the importance of Physician collaboration between proper dosage/examination consultation. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include an aftercare plan, in two of two applicable client records reviewed.
Client # 8 was transferred to the Residential level of care on August 10, 2023 and was discharged on September 3, 2023. The client record did not contain documentation of an aftercare plan.
Client # 14 was admitted to the Residential level of care on November 17, 2023 and was discharged on December 15, 2023. The client record did not contain documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been reeducated about the importance of Aftercare planning during the most recent supervision. The Director of Residential will ensure compliance during monthly chart audits. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information within 30 days of discharge, per facility policy, in two of four applicable records reviewed.
Client # 9 was admitted to the Residential level of care on October 25, 2023 and was discharged on November 15, 2023. The record did not contain documentation of follow-up information.
Client # 10 was transferred to the Residential level of care on January 16, 2024 and was discharged on January 26, 2024. The record did not contain documentation of follow-up information.
This is a repeat citation from the March 9, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Personal Care Coordinators have been educated on the importance follow up's. PCC supervisor will ensure follow up calls are completed by utilizing the 'Task Manager' provided in the EMR. |
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 a review of client records and the facility ' s policy and procedure manual, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated according to facility policy or the regulatory timeframe in four of five applicable client records reviewed. The facility policy indicates that treatment plans are to be updated within seven treatment sessions after transferring from one level of care to another within the facility and every 60 days thereafter.
Client # 17 was transferred to the Outpatient level of care on October 31, 2023 and was transferred to a higher level of care on January 22, 2024. A treatment plan update was due to be completed by November 14, 2023; however, the treatment plan update was not signed as completed until January 18, 2024.
Client # 18 was transferred to the Outpatient level of care on June 19, 2023 and was discharged on October 30, 2023. The individual treatment and rehabilitation plan was completed on July 3, 2023 and the treatment plan update was due no later than September 3, 2023; however, no treatment plan updates were completed prior to the date of discharge.
Client # 19 was transferred to the Outpatient level of care on November 28, 2023 and was active at the time of the inspection. A treatment plan update was completed on December 5, 2023, and another treatment plan update was due no later than February 5, 2024; however, no treatment plan updates were completed prior to the date of discharge.
Client # 20 was transferred to the Outpatient level of care on September 26, 2023 and was active at the time of the inspection. A treatment plan update was completed on October 23, 2023, and the next treatment plan update was due no later than December 23, 2023; however, no treatment plan updates were completed prior to the date of the inspection.
This is a repeat citation from the March 9, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued supervision. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in two of three applicable records reviewed. The facility policy and procedure manual indicates that case consultation notes will be completed prior to transferring from Intensive Outpatient (IOP) to General Outpatient (GOP), and every 90 days while in the GOP level of care.
Client # 18 was transferred to the Outpatient level of care on June 19, 2023 and was discharged on October 30, 2023. The record did not contain documentation of case consultation notes.
Client # 20 was transferred to the Outpatient level of care on September 26, 2023 and was active at the time of the inspection. A case consultation note was completed on October 23, 2023, prior to client transferring from IOP to GOP on October 30, 2023, and the next consultation note was due to be completed by January 30, 2024; however, no additional case consultations were completed prior to the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Director created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued supervision. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include an aftercare plan, in one of one applicable client records reviewed.
Client # 15 was transferred to the Outpatient level of care on August 28, 2023 and was discharged on December 19, 2023. The client record did not contain documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Director of Outpatient has added Aftercare Plans to chart audit checklists to ensure Program Manager is monitoring compliance. Program Manager will also monitor through supervision. |
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.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information within 30 days of discharge, per facility policy, in two of four applicable records reviewed.
Client # 15 was transferred to the Outpatient level of care on August 28, 2023 and was discharged on December 19, 2023. The record did not contain documentation of follow-up information.
Client # 29 was admitted to the Outpatient level of care on July 6, 2023 and was discharged on October 17, 2023. The record did not contain documentation of follow-up information.
This is a repeat citation from the March 9, 2023 and March 4, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued supervision. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the March 9, 2023 March 4, 2022, and May 4, 2021 annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the March 5, 2024 through March 8, 2024 licensing inspection.
A plan of correction for ensuring a complete client record included information relative to the client's involvement with the project to include follow-up information within 30 days of discharge was submitted and approved by the Department for the March 9, 2023 and March 4, 2022 annual licensing inspections. Ensuring a complete client record containing follow-up information was again found to be a deficiency in the March 5, 2024 through March 8, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Residential revised the chart audit tool to ensure compliance. Also, additional training has been assigned through Relias. Failure to comply will result in disciplinary action. Director of Residential made staff aware of what is required and disciplinary actions that will take place. The Director of Residential will ensure plan of correction is monitored through random monthly chart audits. |