INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2023 through March 9, 2023 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee #12 was hired as a counselor on December 19, 2022 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying Bachelor ' s degree but not have the required one year of clinical experience for a bachelor ' s level counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, staff will work to ensure requirements are met. Supervisors were reeducated on staffing requirements. The Director of Human Resources and the Vice President of Clinical Services were also reeducated and will ensure compliance is met. Referenced employee has since separated from Livengrin Foundation. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on March 9, 2023, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as one of the three trash receptacles at the end of the parking lot was uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance staff will perform grounds rounding throughout the day to ensure all receptacles are covered. The Director of Facilities is responsible for ensuring compliance with this regulation is met. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on March 8, 2023, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom as neither were in any client bathrooms in the Detox wing or buildings E, F, and G.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All units have been restocked with paper towels. Additional units were ordered to be placed in the Residential houses. During daily tasks, housekeeping staff will be responsible for ensuring paper towel dispensers are stocked. Director of Facilities is responsible for ensuring compliance. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on March 8, 2023, the facility failed to ensure that heaters were permanently mounted as a space heater was found in the bathroom of the nurse practitioner office in E wing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance department is tasked with inspection rounding. Director of Facilities is responsible for ensuring this deficiency does not occur. The heater has been removed. |
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 February 2022 and January 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 and G were in May and June 2022. The only fire drills documented in building F were in May and August 2022 and January 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to missing documentation of conducted fire drills for each patient building, department heads were reeducated on the requirement of detailed fire drill logs. The compliance department, in conjunction with the Director of Facilities will work together to ensure these documents are completed and turned in each time a fire drill is conducted. After each fire drill, completed forms will be sent to the Compliance Specialist to ensure proper documentation and record keeping. Director of Facilities is responsible for ensuring compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients. The facility failed to follow their policy related to AFA discharges of calling the Emergency Contact within twelve hours in one of two applicable records reviewed.
Client #2 was admitted on March 2, 2023 and discharged Against Facility Advice (AFA) on March 3, 2023. There was no documentation in the client record that the emergency contact was called.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Staff were reeducated on the policy to inform emergency contact in the event a patient AFA's from treatment. Random chart audits will be performed by Program Manager/Director of Detox to ensure compliance. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The organization was granted an extension on it's financial audit by the IRS, expected completion 6/30/2023. This extension was requested due to a change in staff. Proof of the IRS extension was provided at the time of the audit. If this should happen in the future the organization will request an extension from the department as well. The Controller and Finance consultant are responsible to oversee this process. |
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 31 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in 11 records reviewed.
Client #1 was admitted to the Detoxification level of care on June 27, 2022 and was discharged on July 1, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on June 29, 2022, with no client signed consent to release information form signed by the client.
Client #2 was admitted to the Detoxification level of care on May 24, 2022 and was discharged on May 28, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on May 28, 2022, with no client signed consent to release information form signed by the client.
Client #4 was admitted to the Detoxification level of care on September 28, 2022 and was discharged on October 2, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on September 28, 2022, with no client signed consent to release information form signed by the client.
Client #5 was admitted to the Detoxification level of care on March 3, 2023 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on March 6, 2023, with no client signed consent to release information form signed by the client.
Client #6 was admitted to the Detoxification level of care on February 15, 2023 and was discharged on February 19, 2023. The record contained documentation that personally identifying information was released to the Department of Human Services on February 17, 2023, with no client signed consent to release information form signed by the client.
Client #8 was admitted to the Rehabilitation level of care on July 1, 2022 and was discharged on July 27, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on July 6, 2022, with no client signed consent to release information form signed by the client.
Client #9 was admitted to the Rehabilitation level of care on May 28, 2022 and was discharged on June 23, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on June 7, 2022, with no client signed consent to release information form signed by the client.
Client #10 was admitted to the Rehabilitation level of care on December 30, 2022 and was discharged on January 9, 2023. The record contained documentation that personally identifying information was released to the Department of Human Services on January 3, 2023, with no client signed consent to release information form signed by the client.
Client #11 was admitted to the Rehabilitation level of care on October 2, 2022 and was discharged on November 2, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on October 7, 2022, with no client signed consent to release information form signed by the client.
Client #13 was admitted to the Rehabilitation level of care on February 19, 2023 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on February 27, 2023, with no client signed consent to release information form signed by the client.
Client #14 was admitted to the Rehabilitation level of care on February 11, 2023 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on February 13, 2023, with no client signed consent to release information form signed by the client.
This is a repeat citation from the March 4, 2022 and May 4, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has added a consent for verification being run through DHS/Promise to avoid this from happening in the future. Staff will be sure to educate patients on this consent. Program Manager will ensure staff use the appropriate consent through random chart audits. In addition, a new consent has been created to ensure compliance of confidentiality. Of the clients in question, 1 is still active, 2 were active at the time of inspection, 4 were not active at the time of inspection. Active Client has signed the proper consent. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a request for client admission and discharge dates, the facility's recordkeeping system did not allow for the identification of the clients in the Intake, Evaluation, and Referral activity prior to the conclusion of the onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were reeducated on proper procedure for updating level of care change and the corresponding notes. Program Manager/Director of Residential will perform chart audits to ensure compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every thirty days in one of one applicable client record reviewed.
Client #17 was admitted to the partial hospitalization level of care on January 30, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was signed as completed on January 19, 2023, and the treatment plan update was due no later than February 19, 2023; however, the treatment plan update was not signed as completed until March 6, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were reeducated on Treatment Plan time frames. Program Manager will perform chart audits to ensure 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 a review of seven records, the facility failed to ensure that counseling was provided to clients on a regular and scheduled basis, that included individual counseling, at least twice weekly in three records reviewed.
Client #18 was admitted to the partial hospitalization level of care on February 3, 2023 and was active at the time of the inspection. The record contained documentation of only one individual counseling session offered the treatment week of February 3, 2023 through February 9, 2023.
Client #19 was admitted to the partial hospitalization level of care on December 5, 2022 and was discharged on December 21, 2022. The record contained documentation of only one individual counseling session offered the treatment week of December 5, 2022 through December 11, 2022.
Client #20 was admitted to the partial hospitalization level of care on May 25, 2022 and was discharged on June 10, 2022. The record contained no documentation of individual counseling sessions offered the treatment week of May 25, 2022 through May 31, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-educated on requirement to perform two individual session per week during PHP level of care. Program Manager will monitor compliance through random chart audits. The Director of Outpatient programing will complete weekly checks for all PHP clients to ensure Individual Sessions are held. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of four patient records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered in one record reviewed.
Patient # 2 was admitted on May 24, 2022 and was discharged May 28, 2022. The patient was initially administered an agent on May 25, 2022; however, the record contained no client signed informed, voluntary, written consent.
This is a repeat citation from the March 4, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing Staff were reeducated on Buprenorphine Consents. Random Chart audits will be completed by supervisor. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician communicated the initial dose to the person responsible for the administration of medication. It was documented in patient records that the facility ' s Certified Registered Nurse Practitioner (CRNP) rather than the narcotic treatment physician, communicated the initial dose for two of three applicable patients.
Patient #1 was admitted to the Detoxification level of care on June 27, 2022 and transferred to a lower level of care on July 1, 2022. A medication order was written and signed by the CRNP on June 28, 2022.
Patient #2 was admitted to the Detoxification level of care on May 24, 2022 and transferred to a lower level of care on May 28, 2022. A medication order was written and signed by the CRNP on May 25, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time in question, the organization had a contracted medical group that failed to follow facility guidelines. The facility will work to get approval for NP's to prescribe under the NTP. Until this is finalized the facility Physician will be ensure to write all BUP orders. Compliance Specialist will run a monthly report to ensure compliance until additional approval is received. |
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 the facility ' s policy of seven days of discharge in four of four applicable records reviewed.
Client #8 was admitted to the Rehabilitation level of care on July 1, 2022 and was discharged on July 27, 2022. There was no documentation of follow-up information in the record.
Client #9 was admitted to the Rehabilitation level of care on May 28, 2022 and was discharged on June 23, 2022. There was no documentation of follow-up information in the record.
Client #10 was admitted to the Rehabilitation level of care on December 30, 2022 and was discharged on January 9, 2023. There was no documentation of follow-up information in the record.
Client #11 was admitted to the Rehabilitation level of care on October 2, 2022 and was discharged on November 2, 2022. The follow-up information was documented on November 28, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinicians and Patient Care Coordinators were reeducated in the follow up policy and procedure. The facility is revising it's follow up policy for the next round of DDAP audits. The Director of Residential Services will complete random cart audits to ensure compliance is met and is responsible for ensuring continued compliance. |
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 a review of seven client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client in one of three applicable records reviewed.
Client #28 was admitted to the Outpatient level of care on December 6, 2022 and was discharged January 12, 2023. The record contained no documentation that the individual treatment and rehabilitation plan completed on December 13, 2022, was completed with the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-educated on the requirement to document patient participation in the creation of the Treatment Plan. Program Manager/Residential Services will monitor compliance through random chart audits. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of seven client records, the facility failed to ensure that individual treatment and rehabilitation plans included documentation of the proposed type of support services in one of three applicable records reviewed.
Client # 26 was admitted on January 6, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan signed by the client on January 23, 2023, did not include the proposed type of support services.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were reeducated on Treatment Plan documentation requirements. Program Manager/Director of Residential will monitor 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 a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in two of four applicable client records reviewed.
Client #22 was admitted to the Outpatient level of care on October 10, 2022 and was discharged on January 10, 2023. A treatment plan was completed in a higher level of care at the facility on September 19, 2022, and the treatment plan update was due no later than November 19, 2022; however, no treatment plan updates were completed prior to the client ' s discharge.
Client #23 was admitted to the Outpatient level of care on July 5, 2022 and was discharged on September 26, 2022. A treatment plan update was completed on July 12, 2022, and the treatment plan update was due no later than September 12, 2022; however, no treatment plan updates were completed prior to the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-educated on defined time frames for treatment plan completion. Program Manager/Director of Residential will monitor compliance through random chart audits. |
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 the facility ' s policy of seven days of discharge in four of four applicable records reviewed.
Client #22 was admitted to the Outpatient level of care on October 10, 2022 and was discharged on January 10, 2023. There was no documentation of follow-up information in the record.
Client #23 was admitted to the Outpatient level of care on July 5, 2022 and was discharged on September 26, 2022. There was no documentation of follow-up information in the record.
Client #27 was admitted to the Outpatient level of care on September 19, 2022 and was discharged November 4, 2022. There was no documentation of follow-up information in the record.
Client #28 was admitted to the Outpatient level of care on December 6, 2022 and was discharged January 12, 2023. There was no documentation of follow-up information in the record.
This is a repeat citation from the March 4, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has revised it's internal policy to allow additional time for follow up completion. Staff were educated on the policy revision and the requirement to perform follow ups. Program Manager will monitor compliance through random chart audits. |
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 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 6, 2023 through March 9, 2023 licensing inspection.
A plan of correction for obtaining an informed, voluntary, written consent before an agent was administered was submitted and approved by the Department for the March 4, 2022 annual licensing inspection. Obtaining an informed, voluntary, written consent before an agent was administered was again found to be a deficiency in the March 6, 2023 through March 9, 2023 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 seven days of discharge was submitted and approved by the Department for the March 4, 2022 annual licensing inspection. Ensuring a complete client record containing follow-up information was again found to be a deficiency in the March 6, 2023 through March 9, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Manager, in conjunction with the Director of Outpatient services, will ensure the plan of correction is implemented by completing random chart audits. |
709.42(b)(1) LICENSURE Provision of assessments
709.42. Project management.
(b) The intake project or treatment service providers shall have a written procedure for the performance of the following functions:
(1) Arrangement for the provision of needed medical, functional, psychological, psychiatric, social or vocational diagnostic assessments.
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Observations
Based on a review of three client records, the facility failed to make arrangements for the provision of needed medical, functional, psychological, psychiatric, social or vocational diagnostic assessments in one of three applicable records reviewed.
Client #29 was admitted to the Intake, Evaluation, and Referral level of care on April 2, 2022. The client record documented that the client was identified for needing psychiatric follow up but there was no documentation a referral or follow up was completed. The facility procedures state " if clinically unable to participate in our treatment program the client will be referred for appropriate alternative treatment. "
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were reeducated on proper chart documentation and protocol. Director of Admissions will ensure compliance is met through random chart audits. |