INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on March 8 through March 11, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Livengrin Foundation, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on April 4, 2010.
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Plan of Correction
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a tour of the facility's physical plant and an interview with the facility director of operations, the facility failed to ensure the building's grounds were safe and in good repair at all times.
The findings include:
The facility's physical plant was inspected on March 9, 2010 between the hours of 1:10 p.m. and 3:00 p.m.. During this inspection, at 1:20 p.m., it was discovered that the landing immediately outside the emergency exit on the men's detox wing had a softball sized hole. The landing is composed of metal that had rusted out. The damaged landing posed a threat to to the safety and well being of the residents, employees, and visitors of the facility.
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Plan of Correction
The Director of Facilities Management will ensure that the metal landing outside of the Detox wing will be repaired. Compliance will be monitored by the Director of Administrative Services. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room.
Findings:
The physical plant inspection was conducted on March 9, 2010 between 1:10 PM and 3 PM. The facility failed to ensure privacy in order that counseling sessions cannot be seen or heard outside the counseling room. The large group room on the lower level has an uncovered diamond shaped window on the door. A counseling session was observed taking place during the tour and the licensing specialists could clearly view the participants from outside of the room.
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Plan of Correction
The Director of Facilities Management painted over the window on 03/30/2010. Compliance was observed by the Director of Administrative Services. |
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 an inspection of the physical plant and an interview with the nutrition director, the facility failed to provide documentation of cold food being stored at or below 40F and hot food being served at 140F or above.
The findings include:
The physical plant was inspected on March 9, 2010 from 1:10 PM to 3:00 PM. The facility had a large double door in the food preparation area. When the nutrition director was asked to furnish the temperature log for this unit, the licensing specialists were informed that the facility does not keep a log for the refrigerator unit. Additionally, when the nutrition director was asked to provide a log for the serving food temperatures, the licensing specialists were advised there is no log kept to record the requested data. There was no documentation to determine if the cold food is stored at 40F and the hot food is served at 140F or above in these areas.
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Plan of Correction
On 03/09/2010, the Director of Administrative Services created a log for dietary staff to monitor the temperature of the refrigerator unit on a daily basis. Compliance will be monitored by the Director of Administrative Services. On 3/12/10, the Director of Administrative Services created a log for dietary staff to monitor hot food temperatures. Compliance will be monitored by the Director of Administrative Services. |
709.82(e)(4) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
Based on a review of the facility's letters of agreement and an interview with the Quality Management / Training Director, the facility failed to assist clients in obtaining economic services when necessary.
The findings include:
On March 9, 2010 letters of agreement were reviewed. There was no documentation of a letter of agreement for economic services. When the Quality Management/ Training Director was asked if the facility had a letter of agreement for economic services or documentation in any of the client records of a referral for economic services, the training director confirmed that they did not have an agreement in place.
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Plan of Correction
The Director, TQM will obtain a referral agreement for economic services. Compliance will be monitored by the President/CEO. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on an inspection of the facility 's physical plant, the facility failed to display to the public the hours of project operation.
Findings:
A physical plant inspection was conducted on March 9, 2010 at 1:10 pm. The hours of project operation were required to be displayed conspicuously to the general public. The facility did not display the hours of project operation.
This is a repeat citation.
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Plan of Correction
The Director of Facilities Management will ensure that the hours of project operation are displayed conspicuously to the general public. Compliance will be monitored by the Director of Administrative Services. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation and conversation with the Quality Management staff it was determined that the project failed to develop goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010.
The findings were:
A review of administrative documents on March 8 through March 9, 2010 indicated that the annual goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 were missing.
A conversation with the Quality Management Staff on March 8, 2010 confirmed that the annual goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 had not been developed.
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Plan of Correction
The President/CEO will develop goals and objectives for the fiscal year of 7/1/09 to 6/30/10. The President of the Board of Directors will be responsible to ensure that the corrective action is implemented. Compliance will be monitored by the Director, TQM. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on the physical plant tour on March 9, 2010 the facility failed to have a service fee schedule posted in a prominent place.
The findings include:
A physical plant tour was conducted between the hours of 1:00 p.m. and 3:00 p.m.. During inspection it was confirmed by the Facility Director of Operations that the fees were not posted.
This is a repeat citation from the previous licensing visit.
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Plan of Correction
The Director of Administrative Services posted Livengrin's fees in the Admissions areaon 3/11/10. Compliance will be monitored by the Director, TQM. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project 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 and kept on file.
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Observations
Based on a review of the client orientation information, client records, client rights form and an interview with the Quality Management Staff person, the facility failed to inform clients of all of their client rights.
The findings include:
Seventeen client records were reviewed on March 10 and 11, 2010. All clients are required to be informed of all of their client rights. Client rights documentation contained in client rights form did not document all the client rights required. This was confirmed by the Quality Management staff person in an interview which took place on March 10, 2010.
The facility failed to notify the clients of the following client rights:
A client has the right to inspect his own records. The project 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 and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information from his record.
Client records # 1, 3, 4, 5, 6, 7, 8, 16, 17 failed to inform the client that the project 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 and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information from his record.
Client records # 9,10,11,12 and 13 failed to inform the client that they have the right to inspect his own records. The project 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 and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information from his record.
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Plan of Correction
The Director, TQM will amend the Client Rights document to include all required rights. Compliance will be monitored by the President/CEO. |
709.63(a)(6) LICENSURE Aftercare plan
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:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records, the facility failed to complete an aftercare plan where required.
The findings include:
Seventeen client records were reviewed on March 10 and 11, 2010. Of those records reviewed, five were detox client records. Of those five detox client records three clients were discharged and two out of the three discharged records required aftercare plans. The facility failed to document an aftercare plan in client records # 10 and 12.
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Plan of Correction
In a meeting, on 3/24/10, the Director of Detox Services reminded detox counselors of the need to document aftercare plans where required. The Director of Detox Services will randomly review closed detox charts to ensure compliance. Oversight will be provided by the Director, TQM. |
709.64(c)(4) LICENSURE Economic Support Services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
Based on a review of the facility's letters of agreement and an interview with the Quality Management / Training Director, the facility failed to assist clients in obtaining economic services when necessary.
The findings include:
On March 9, 2010 letters of agreement were reviewed. There was no documentation of a letter of agreement for economic services. When the Quality Management/ Training Director was asked if the facility had a letter of agreement for economic services or documentation in any of the client records of a referral for economic services, the training director confirmed that they did not have an agreement in place.
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Plan of Correction
The Director, TQM will obtain a referral agreement for economic services. Compliance will be monitored by the President/CEO. |
709.52(e)(4) LICENSURE Economic support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
Based on a review of the facility's letters of agreement and an interview with the Quality Management / Training Director, the facility failed to assist clients in obtaining economic services when necessary.
The findings include:
On March 9, 2010 letters of agreement were reviewed. There was no documentation of a letter of agreement for economic services. When the Quality Management/ Training Director was asked if the facility had a letter of agreement for economic services or documentation in any of the client records of a referral for economic services, the training director confirmed that they did not have an agreement in place.
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Plan of Correction
The Director, TQM will obtain a referral agreement for economic services. Compliance will be monitored by the President/CEO. |