INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2012 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.
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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, the facility failed to hire a counselor who meets the qualification of counselor in one of thirteen personnel records.
The findings include:
Twenty-two personnel records were reviewed on March 7-8, 2012. Thirteen of the twenty-two personnel records were reviewed for counselor status.
Employee #11 has a nursing certification. A counselor who has a nursing certification must have a degree from an accredited school of nursing and 1 year of counseling experience in a health or human service agency, preferably in a drug and alcohol setting. Employee #11 has the 1 year experience, but was unable to provide a copy of their nursing degree.
Employee #1 has a certification as a counselor from the State of New Jersey which is current, however, reciprocity is needed to practice in the State of Pennsylvania.
An interview with the Quality Improvement Director on March 13, 2012 confirmed the findings.
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Plan of Correction
The employee is in the process of obtaining reciprocity from the State of Pennsylvania. The Program Manager will ensure that the process is completed. Oversight will be provided by the Director, Total Quality Management. The Director, Total Quality Management will review all credentials of all clinical staff to ensure that they meet licensing standards. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel records.
The findings include:
Twenty-two personnel records were reviewed on March 7-8, 2012. One personnel record pertained to the project director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the facility director since October 26, 1987. The facility training year is from July 1, 2010 through June 30, 2011. Employee # 1 had documentation of 5 training hours documented for the 2010-2009 training year.
A discussion with the Quality Improvement Director on March 8, 2012 confirmed the findings.
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Plan of Correction
The Director, Total Quality Management, will remind the Project Director of the need to obtain twelve credits for each training year. The Director, Total Quality Management, will monitor compliance on a monthly basis. If compliance has not been met, the Director, Total Quality Management will review the requirement with the Project Director, on a monthly basis, until the requirement has been met. |
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, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in three of four partial hospitalization activity client records.
The findings include:
Eighteen client records were reviewed on March 12-16, 2012. Four of the eight client records reviewed were partial hospitalization activity records, #15, 16, 17 and 18. A psychosocial evaluation was required in three of those records, #16, 17 and 18. An interview with facility staff on March 15, 2012 confirmed the findings.
The psychosocial evaluations in client records #16, 17 and 18 did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client #16 was admitted on February 16, 2012 and discharged on March 6, 2012. The psychosocial evaluation was to be completed within 7 days of the client's admission date. Client #16's psychosocial evaluation was to be completed by February 23, 2012. Their psychosocial evaluation was completed on February 27, 2012, 4 days after the required completion date.
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Plan of Correction
In a meeting on 3/16/12, the Program Manager reminded all counselors that psychosocial evaluations for all patients need to include all required elements, and that psychosocial evaluations need to be completed within seven days of the patient's admission date. The Program Manager will randomly monitor charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document treatment plans within the facility's allotted time in three of four partial hospitalization activities client records.
The finding includes:
Eighteen client records were reviewed on March 12-13, 2012. Four of the client records were from the partial hospitalization activity, # 15, 16, 17 and 18, of which three were reviewed for treatment plan content. Per the facility's policy, treatment plans will be completed within 7 days of the client's admission date into the partial hospitalization program after the completion of the client's biopsychosocial history and evaluation. An interview with facility staff on March 15, 2012 confirmed the findings.
Client #16 was admitted to the partial hospitalization program on February 28, 2012 and discharged on March 6, 2012. The treatment plan was completed on February 21, 2012, seven days before the completion of the client's psychosocial evaluation which was completed on February 27, 2012.
Client #18 was admitted to the program on September 30, 2011 and discharged on October 21, 2011. Client record #18's treatment plan was completed on November 4, 2011 before the completion of the client's personal history which was partially completed on September 26, 2011 (initiated at another level of care within the project).
Client #17 was admitted to the program on February 14, 2012 and discharged on February 22, 2012. The client's treatment plan was completed on February 16, 2012. The therapist signed the treatment plan on February 16, 2012 and the client did not sign the treatment plan as of February 22, 2012, their discharge date. It was unable to be determined if it was developed with the client. The partial hospitalization standard stated an individual treatment and rehabilitation plan shall be developed with a client.
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Plan of Correction
In a meeting, on 3/16/12, the Program Manager reminded all counselors of the need to complete treatment plans within seven days of a patient's admission, after completion of the psychosocial evaluation, and that the treatment plan needs to be developed with the patient. The Program Manager will randomly monitor patient charts on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
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, the facility failed to document case consultations notes in two of four partial hospitalization activity client records.
Findings:
Eighteen client records were reviewed on March 12-16, 2012. Four of the client records were from the partial hospitalization activity, # 15, 16, 17 and 18. Per the facility's policy, case consultations are to be documented every 90 days for outpatient and at least once prior to discharge in inpatient. An interview with facility staff on March 15, 2012 confirmed the findings.
Client #16 was admitted on February 28, 2012 and discharged on March 6, 2012. Their case consultation was documented in the system February 29, 2012 but the case consultation signed by the counselor stated it was done March 1, 2012. It could not determined when the case consultation was actually completed.
Client #17 was admitted on February 14, 2012 and discharged on February 22, 2012. Their case consultation was documented a day after the client was discharged, February 23, 2012.
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Plan of Correction
In a meeting, on 3/16/12, the Program Manager reminded all counselors of the need to document a case consultation for all patients. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summaries in three of four partial hospitalization activities records reviewed.
The findings include:
Eighteen client records were reviewed on March 12-16, 2012. Four of the client records were reviewed from the partial hospitalization program activity, # 15, 16, 17 and 18. Per the facility's policy, discharge summaries are required within 7 days of the client's discharge date. Discharge summaries were not documented in client records, #16, 17 and 18.
Client #16 was admitted on February 16, 2012 and discharged on March 6, 2012. Their discharge summary was to be completed by March 13, 2012. As of the date of the inspection, the discharge summary was not documented client record #16.
Client #17 was admitted on February 14, 2012 and discharged on February 22, 2012. Their discharge summary was to be completed by February 29, 2012. As of the date of the inspection, the discharge summary was not documented client record #17.
Client #18 was admitted on September 30, 2011 and discharged on October 21, 2011. Their discharge summary was to be completed by October 28, 2011. As of the date of the inspection, the discharge summary was not documented client record #18.
An interview with facility staff on March 15, 2012 confirmed the findings.
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Plan of Correction
In a meeting, on 3/16/2012, the Program Manager reminder all counselors of the need to document a discharge summary for all patients. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. Discharge Summaries will be documented in patient records #16, #17 and #18 by 5/9/12. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that the client was notified of his/her right to revoke client consents to release information verbally or in writing.
The findings include:
Eighteen client records were reviewed on March 12-16, 2012. Eighteen client records were required to have informed and voluntary consent forms that documented on the form that the client is notified of his/her right to revoke client consent to release information verbally or in writing. The right to revoke the consent verbally or in writing was not documented on the informed and voluntary consent forms for insurance companies in client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 and 18.
The facility exceeded 4 PA Code. 255.5 by exceeding what it to be sent out to a employer. Per the State Law 255.5 Projects and Coordinating Bodies: Disclosure of Client Oriented Information (a) (6) states that employers can only get whether or not the client is in treatment. The facility exceeded PA 255.5 (a) (6) by faxing or sending letters to the employer in records, #10 and 12.
Also, in a reviewed of client records, the facility conducted family sessions or made calls and spoke to family members pertaining to the client while they were in treatment. The facility did not have a consent to release form in place for the family member to attend sessions or a consent to release form in place for the conversations that took place over the phone while the client was in treatment. This occurred in client records, #7, 8, 11,12, 13, 14
An interview with the Quality Improvement Director on March 7, 2012 confirmed the findings.
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Plan of Correction
The Director, Total Quality Management,will revise all relavent consents by 4/30/12. Revised consents will state that the patient has the right to revoke consents verbally or in writing. The revised consents will be sent to the Information Technology Department by 4/30/12. The Deparment will remove the incorrect consents and add the revised consents to the electronic record by 4/30/12. The Director, Total Quality Management will inform the Program Manager, by 4/30/12, that the revised consents are contained in the electronic record. The Program Manager will inform all Counselors, by email, that revisions have been made to consents. All future patients, as of 4/30/12, will be required to read and sign the revised consents. All current patients will be required to read and sign the revised consents. In a meeting, on 3/16/12, the Program Manager informed all Counselors of the need to document a release for all family members included in family sessions or phone calls. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document the client's physical examination in four of four short-term detoxification activity client records.
The findings include:
Eighteen client records were reviewed on March 12-16, 2012. Four of the eighteen client records came from the short-term detoxification activity, #1, 2, 3 and 4. Per the facility's policy and the State standards, physical exams are to include the date the physical took place, the client's vital signs, review of the client organ system, the clients general appearance and the physician's impressions of the client. Client physical exams did not include the client's general appearance and the physician's impressions in client records, #1, 2, 3 and 4. An interview with facility staff on March 15, 2012 confirmed the findings.
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Plan of Correction
In a meeting, on 3/20/12, the Clinical Director reminded all Nurse Practicioners of the need to include the patient's general appearance and physician's impressions in the patient record. The Program Manager will randomly review patinet charts on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document the client's physical examination in eight of eight residential treatment and rehabilitation activity client records.
The findings include:
Eighteen client records were reviewed on March 12-16, 2012. Eight of the eighteen client records came from the residential treatment and rehabilitation activity, #7, 8, 9, 10, 11, 12, 13 and 14. Per the facility's policy and the State standards physical exams are to include the date the physical took place, the client's vital signs, review of the client organ system, the clients general appearance and the physician's impressions of the client. Documentation of the physical exams reviewed did not include the client's general appearance and the physician's impressions in client records, #7, 8, 9, 10, 11, 12, 13 and 14. An interview with facility staff on March 15, 2012 confirmed the findings.
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Plan of Correction
In a meeting, on 3/20/12, the Clinical Director reminded all Nurse Practicioners of the need to include general appearance and physician's impressions of the patient in the patient record. The Program Manager will randomly monitor patient charts to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in eight of eight residential treatment and rehabilitation activity client records.
The findings include:
Eighteen client records were reviewed on March 12-16, 2012. Eight of the eighteen client records reviewed were residential treatment and rehabilitation activity records, #7, 8, 9, 10, 11, 12, 13 and 14. A psychosocial evaluation was required in eight of those records, #7, 8, 9, 10, 11, 12, 13 and 14. An interview with facility staff on March 16, 2012 confirmed the findings.
The psychosocial evaluations in client records #7, 8, 9, 10, 11 and 12 did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and negative factors.
Also, per the facility's policy psychosocial evaluations are to be completed within 7 days of the client's admission date.
Client #12 was admitted on January 12, 2012 and discharged on February 6, 2012. Their discharge summary was to be completed by January 19, 2012. As of the date of the client's discharge on February 6, 2012, there was no documentation of the client's psychosocial evaluation in client record #12.
Client #13 was admitted on December 16, 2011 and discharged on January 2, 2012. Their psychosocial evaluation was to be completed by December 23, 2011. As of the date of the client's discharge on January 2, 2012, there was no documentation of the client's psychosocial evaluation in client record #13.
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Plan of Correction
In a meeting, on 3/16/12, the Program Manager reminded all Counselors of the need to include all required elements in the Psychosocial Evaluation, and that the Psychosocial Evaluation needs to be completed within seven days of admission. The Program Manager will randomly monitor patient charts to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations notes in four of eight residential treatment and rehabilitation activity client records.
Findings:
Eighteen client records were reviewed on March 12-16, 2012. Eight of the client records were from the residential treatment and rehabilitation activity, # 7, 8, 9, 10, 11, 12, 13 and 14. Per the facility's policy, case consultations are to be documented every 90 days for outpatient records and at least one prior to discharge in the inpatient records. An interview with the facility staff on March 16, 2012 confirmed the findings.
Client #11 was admitted on November 25, 2011 and discharged on December 14, 2011. As of the date of the client's discharge December 14, 2011, client #11 did not have documentation of a case consultation.
Client #12 was admitted on January 2, 2012 and discharged on January 27, 2012. As of the date of the client's discharge January 27, 2012, client #12 did not have documentation of a case consultation.
Client #13 was admitted on January 12, 2012 and discharged on February 6, 2012. As of the date of the client's discharge February 6, 2012, client #13 did not have documentation of a case consultation.
Client #14 was admitted on December 16, 2011 and discharged on January 2, 2012. As of the date of the client's discharge January 2, 2012, client #14 did not have documentation of a case consultation.
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Plan of Correction
In a meeting, on 3/16/12, the Program Manager reminded all Counselors of the need to complete a case consultation for all patients. The Program Manager will randomly monitor patient charts to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summaries in four of eight residential treatment and rehabilitation activity records reviewed.
The findings include:
Eighteen client records were reviewed on March 12-16, 2012. Eight of the client records were reviewed from the residential treatment and rehabilitation activity, # 11, 12, 13 and 14. Per the facility's policy discharge summaries are required within 7 days of the clients discharge date. Discharge summaries were not documented in client records, #11, 12, 13 and 4..
Client #11 was admitted on November 25, 2011 and discharged on December 14, 2011. The discharge summary was to be completed by December 21, 2011. The discharge summary was not completed until December 22, 2011, one day after the required date in client record #11.
Client #12 was admitted on January 2, 2012 and discharged on January 27, 2012. Their discharge summary was to be completed by February 3, 2012. As of the date of the inspection, the discharge summary was not documented client record #12.
Client #13 was admitted on January 12, 2012 and discharged on February 6, 2012. Their discharge summary was to be completed by February 13, 2012. As of the date of the inspection, the discharge summary was not documented client record #13.
Client #14 was admitted on December 16, 2011 and discharged on January 2, 2012. Their discharge summary was to be completed by January 9, 2012. As of the date of the inspection, the discharge summary was not documented client record #14.
An interview with facility staff on March 16, 2012 confirmed the findings.
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Plan of Correction
In a meeting, on 3/16/2012, the Program Manager reminded all Counselors of the need to document a discharge summary for all patients. The Program Manager will randomly monitor patient charts to ensure compliance. Oversight will be provided by the Director, Total Quality Management. Discharge summaries for patient records #11, #12,#13 and #14 will be completed by 5/9/12, and will be monitored by the program manager. |