INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 10, 2008 through March 13, 2008 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 16, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records and personnel records, the facility failed to provide documentation that each counselor met the qualifications for this position. The facility did not identify an intern that provided counseling as either a counselor or counselor assistant and did not provide the documentation of qualifications for the intern. The intern provided group counseling sessions in the partial hospitalization program in client record #1.
|
Plan of Correction
5/27/2008 - any person providing clinical services to patients, such as interns, will be treated like counselors or counselor assistants, depending on educational and experiential qualifications. For interns who are considered counselor assistants, supervisors will conduct and document the required supervision. In a meeting, the TQM Director will educate supervisors on the new process. Compliance will be monitored by the TQM Director. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of personnel records and documentation of supervision, the facility failed to document supervision of counselor assistants in three of three records reviewed, #5, 8 and 10. Weekly supervision sessions were documented by the counselor assistants themselves with no input documented by their supervisors.
|
Plan of Correction
In a meeting, the Clinical Director will inform counselors that weekly supervision of counselor assistants must be completed by the supervising counselor. The Clinical Director will conduct random audits of weekly supervision notes. The Director, TQM will meet quarterly with the Clinical Director to monitor compliance. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
|
Observations
Based on a review of the policy and procedures, the facility did not document a complete staff development policy. The policy did not address who was responsible or the time frames for completion of the assessment of staff training needs and the overall training plan.
|
Plan of Correction
The Project Director or his designee will revise the staff development program to include the required elements. A copy of the revised program will be forwarded to the Clinical Director for compliance monitoring. The new program will be in place for the 2008/2009 training year. |
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.
|
Observations
Based on a review of personnel and training records, the facility failed to document that employee #1 earned 12 training hours for the July 2006 to June 2007 training year. Employee #1 had only 4 hours of training documented for the training year.
|
Plan of Correction
Employee #1 will complete 12 training hours for training year 2007/2008. Compliance will be monitored by the TQM Director. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
Based on a review of the physical plant conducted on March 13, 2008, the facility did not ensure the second means of egress from the first floor of the 500 Building was unobstructed. A new frame was installed in the emergency egress window and surrounding vegetation had grown up blocking the exit.
|
Plan of Correction
The Director of Administrative Services instructed the Director of Facilities Management to remove the frame and surrounding vegetation to insure unobstructed egress from the second means of egress for the 500 Building. Work has been completed and inspected by the Director of Administrative Services. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
|
Observations
Based on a physical plant inspection conducted on March 13, 2008, the facility did not install smoke detectors or fire alarms so that each person with a hearing impairment would be alerted in the even of a fire in the client residential building identified as Building 500.
|
Plan of Correction
The Director of Administrative Services instructed the Director of Facilities Management to install smoke detectors in Building 500, that would alert hearing impaired patients/staff in the event of a fire. The completed installation will be inspected by the Director of Administrative Services to insure compliance. |
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.
|
Observations
Based on a review of fire drill records, the facility did not document participation in fire drills for staff and clients within the partial hospitalization program on the following dates: 7/31/07, 9/3/07, 10/30/07, 12/8/07, 1/31/08 and 2/24/08.
|
Plan of Correction
The Director of Administrative Services instructed the Director of Facilities Management to conduct a monthly fire drill during partial hospitalization program hours. Compliance will be monitored by the Director of Administrative Services. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of the fire drill records, the facility did not conduct a fire drill during sleeping hours from July 2007 to February 2008. Based on a review of the client schedules, wake-up occur between 5:30 a.m. and 6:00 a.m. One fire drill that occurred closet to the clients' sleeping hours was on 12/8/07 at 6:45 a.m.
|
Plan of Correction
The Director of Administrative Services instructed the Director of Facilities Management to conduct a fire drill during patient sleeping hours, at least every 6 months. Compliance will be monitored by the Director of Administrative Services. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on a review of client records, the facility failed to document a medical history in two of three client records reviewed, #1 and 3.
|
Plan of Correction
In a meeting, the Clinical Director will remind counselors of the need to document a medical history for all Partial Hospitalization Program patients. The Clinical Director will conduct a random audit of patient charts. The TQM Director will insure compliance through chart auditing. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in three of three records reviewed, #1, 2 and 3. Psychosocial evaluations did not provide the counselor's assessment of the client's assets/strengths, support systems and negative factors that may inhibit treatment in two records, #2 and 3. The psychosocial evaluation was not documented in one of three client records reviewed, #1.
|
Plan of Correction
In a meeting, the Clinical Director will remind counselors of the need to document a Psychosocial evaluation for each patient, to include patients' assets/strengths, support systems and negative factors that may inhibit treatment. The Clinical Director will conduct random audits of patient charts to insure compliance. Compliance will also be monitored by the Clinical Supervisors and the TQM Director through use of a Clinical audit tool. |
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.
|
Observations
Based on a review of client records, the facility failed to document a treatment plan update within 30 days of the comprehensive treatment plan in one of one client record reviewed, #2.
|
Plan of Correction
In a meeting, the Clinical Director will remind counselors of the requirement to document a treatment plan update within 30 days of the comprehensive treatment plan. The Clinical Director will conduct random chart reviews. Compliance will be monitored by the TQM Department through chart auditing. |
709.82(e)(1) 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:
(1) Medical/dental.
|
Observations
Based on a review of referral agreements and client records, the facility failed to demonstrate assistance for clients in obtaining dental support services.
|
Plan of Correction
The TQM Director will obtain a referral agreement for dental support services. Compliance will be monitored by the Clinical Director. |
709.83(a)(5) 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:
(5) Medication records.
|
Observations
Based on a review of client records, the facility failed to document medication records in two of three client records reviewed, #1 and 3.
|
Plan of Correction
In a meeting, the Clinical Director will remind counselors of the need to document medication records for all partial hospitalization program patients. The Clinical Director will conduct random chart audits to insure compliance. Compliance will also be monitored by the TQM Director through chart auditing. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based on a review of the administrative records, the facility failed to document notification of the 2006-2007 annual report to the public.
|
Plan of Correction
The PR Director provided public notice of the availability of the 2006-2007 annual report, on 3/14/08. He will insure that notice to the public is documented for subsequent years. Compliance will be monitored by the TQM Director. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of the letters of agreement, the facility failed to document an agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage.
|
Plan of Correction
The TQM Director will obtain a referral agreement with a hospital which specifies the requirement for 24 hour emergency psychiatric and medical coverage. Compliance will be monitored by the Clinical Director. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on the physical plant inspection conducted on March 13, 2008, the facility failed to maintain client identity. Client's first and last names were posted on name tags on their bedroom doors.
|
Plan of Correction
In a meeting, the Rehab Program Manager will instruct staff techs that name tags on patient doors need to include last initial rather than last name. Compliance will be monitored by the TQM Director. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in two of four records reviewed, #2 and 3. Psychosocial evaluations were historical and based on what the client reported to the counselor and not the counselor's assessment of that information.
|
Plan of Correction
The Clinical Director will revise the PSA evaluation to include assessment of reported information. In a meeting, the Clinical Director will distribute the revised PSA and instruct counselors to complete the assessment section of the PSA. The Clinical Director will conduct random chart audits to assess compliance. The TQM Director will also monitor compliance through chart auditing. |
709.63(a)(7) LICENSURE Discharge summary
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:
(7) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to document a complete discharge summary in two of three client records reviewed, #3 and 5. Discharge summaries did not provide the specific reason(s) for the client entering treatment or the client's response to treatment goals.
|
Plan of Correction
In a meeting, the Clinical Director will remind counselors of the requirement for Discharge Summaries to include the specific reason for a patient entering treatment, and the patients response to treatment goals. The Clinical Director will conduct random chart audits to monitor compliance. Compliance will also be monitored by the TQM Director through chart auditing. |
709.64(c)(1) LICENSURE Medical/dental support services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
|
Observations
Based on a review of referral agreements and client records, the facility did not document the project assisting the clients in obtaining dental support services.
|
Plan of Correction
The TQM Director will obtain a referral agreement for dental services. Compliance will be monitored by the Clinical Director. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in three of four client records reviewed, #1, 3 and 4. The psychosocial evaluations in #1, 3 and 4 did not include the counselor's assessment of the client's assets/strengths. The psychosocial evaluations in #3 and 4 did not include the counselor's assessment of the client's support systems and negative factors that may inhibit treatment.
|
Plan of Correction
In a meeting, the Clinical Director will remind counselors of the need to include all required elements in the psychosocial. The Clinical Director will conduct random chart audits to monitor compliance. The TQM Director will also monitor compliance through chart auditing. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility did not document treatment plan updates within 15 days from the date of the comprehensive treatment plans in three of three client records reviewed, #4, 5 and 6. The treatment plan update in #4 was due on 3/6/08 and was not completed. The treatment plan update in #6 was due on 12/3/07 and was not completed. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in one record reviewed, #5.
|
Plan of Correction
In a meeting, the Clinical Director will remind counselors of the requirement to update treatment plans within 15 days of the comprehensive treatment plan. He will also remind counselors to include patient's progress in relationship to the stated goals of the comprehensive treatment plan. The Clinical Director will conduct random audits for compliance. Compliance will also be monitored by the TQM Director through the chart auditing process. |
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
|
Observations
Based on a review of referral agreements and client records, the facility failed to demonstrate assistance for clients in obtaining dental support services.
|
Plan of Correction
The TQM Director will obtain a dental agreement. Compliance will be monitored by the Clinical Director. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
|
Observations
Based on a review of client records, the facility failed to document the record of services in three of four client records reviewed, #1, 2 and 3.
|
Plan of Correction
In a meeting, the Clinical Director will remind counselors of the requirement to complete the record of services. The Clinical Director will conduct random chart audits to monitor compliance. Compliance will also be monitored by the TQM Director through the chart auditing process. |