INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on March 12, 2018 through March 13, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Livengrin Foundation, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that Employee #2 had a training plan for the current training year (7/1/17-6/30/18) documented in the employee's personnel/training file.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Individual training plans are done at the time of staff members performance reviews. On 4.3.18, the Human Resources Coordinator reached out to management regarding the importance of timely reviews. All outstanding reviews and training plans have since been submitted. The HR Coordinator will continue to track outstanding performance and training reviews on a monthly basis. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that 12 employees received the minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #12 was hired as a counselor on 11/21/2016 and was due to have the communicable disease trainings no later than 11/21/17. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #13 was hired as a staff tech on 8/15/2011 and was due to have the communicable disease trainings no later than 8/15/13. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #14 was hired as maintenance personnel on 8/07/2015 and was due to have the communicable disease trainings no later than 8/07/17. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #15 was hired as an intake specialist on 4/09/2014 and was due to have the communicable disease trainings no later than 4/09/16. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #16 was hired as an intake specialist on 12/11/2015 and was due to have the communicable disease trainings no later than 12/11/17. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #17 was hired as an assessor on 12/21/2015 and was due to have the communicable disease trainings no later than 12/21/17. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #18 was hired as an assessor on 8/09/2015 and was due to have the communicable disease trainings no later than 8/09/17. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #19 was hired as an assessor on 9/05/2015 and was due to have the communicable disease trainings no later than 9/05/17. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #20 was hired as a FRAT director on 1/06/2014 and was due to have the communicable disease trainings no later than 1/06/16. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #21 was hired as a FRAT director on 6/17/2011 and was due to have the communicable disease trainings no later than 6/17/13. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #22 was hired as a nurse tech on 3/05/2016 and was due to have the communicable disease trainings no later than 3/05/18. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #23 was hired as a nurse tech on 5/04/2015 and was due to have the communicable disease trainings no later than 5/04/17. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The staff in question are required to attend an upcoming offering of TB/STD on April 13,2018 or find their own HIV/AIDs or TB/STD training externally by July 1, 2018, based on their needs. If the offending staff do not comply, they will face disciplinary action. The Education Coordinator will continue to monitor on a quarterly basis staff training compliance and report it to appropriate management. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that Employee #2 had a 2017 annual staff performance evaluation documented in the employee's personnel file as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Staff members performance reviews are done a yearly basis. On 4.3.18, the Human Resources Coordinator reached out to management regarding the importance of timely reviews. All outstanding reviews and training plans have since been submitted. The HR Coordinator will continue to track outstanding performance reviews on a monthly basis. |
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 the review of 17 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 client records.
Client #12 was admitted into the residential level of care on 4/24/2017 and was discharged on 5/22/2017. There was documentation that a telephone conversation occurred between facility staff and a local pharmacy on 4/26/17; however, there was no proper consent to release information form signed by the client prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Quality Improvement created a specific 'Pharmacy' release form to be completed at the time of admission. All admissions staff such as intake specialists and assessment counselors along with nursing staff have been made aware of this new process in a memo on April 23, 2018. Moving forward, Intake specialist will sign the 'Pharmacy' release with the client during admissions process. Nursing staff will follow up with client once admitted to review release for accuracy. |
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 5 partial hospitalization level of care client records, the facility failed to document an individual treatment and rehabilitation plan in 1 client record. Additionally, the facility failed to document the frequency of services on the individual treatment plan in 2 client records.
Client #13 was admitted into the PHP level of care on 3/02/2018 and was still active at the time of the inspection. There was no individual, comprehensive treatment plan documented in the record as of the date of the inspection.
Client #14 was admitted into the PHP level of care on 2/26/2018 and was still active at the time of the inspection. The comprehensive treatment plan, dated 2/28/18, was missing the frequency of services.
Client #16 was admitted into the PHP level of care on 1/24/2018 and was discharged on 2/05/2018. The comprehensive treatment plan, dated 1/26/2018, was missing the frequency of services.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The importance of treatment plans having frequency of services was shared with the offending clinical staff. The identified staff members are required to attend an upcoming offering of the Clinical Documentation Compliance 101 training on May 17th, 2018, which will focus on treatment plan requirements. The Director of Quality Improvement will be responsible for the ongoing monitoring of treatment plan compliance. |