D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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LIVENGRIN FOUNDATION, INC.
4833 HULMEVILLE ROAD
BENSALEM, PA 19020

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Survey conducted on 05/04/2021

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on May 3, 2021 through May 4, 2021 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.	Plan of Correction
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.
Observations Based on a review of personnel files and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure that all staff completed the mandatory 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training within the regulatory time frame.Employee #9 was hired as a counselor on June 3, 2019. The HIV/AIDS and TB/STD trainings were due no later than June 3, 2020. There was no documentation in the record that the trainings were completed at the time of inspection. The findings were discussed with facility staff during the licensing process.	Plan of Correction The VP of Human Resources will develop and implement a policy to aid is training compliance. Continued non-compliance may result in disciplinary action.
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.
Observations Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of twenty-eight records reviewed. Client # 11 was admitted October 19, 2020 and was discharged March 3, 2021. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information. The findings were discussed with facility staff during the licensing process.	Plan of Correction The employee involved will be required to attend confidentiality and consent trainings. A written warning will be issued to the employee and a copy will be placed in the employees HR file. The Behavioral Health Technician & Patient Care Coordinator Manager & Director of Residential Services will ensure the employee is properly educated and the HR file is documented. Additional instances may result in progressive disciplinary action.
709.28 (c) (6) 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 must be in writing and include, but not be limited to: (6) Date, event or condition upon which the consent will expire.
Observations Based on a review of client records, the facility failed to document the date, event, or condition upon which a consent to release information form will expire in 28 of 28 records reviewed.Client #1 was admitted into the partial hospitalization level of care on April 19, 2021 and was active at the time of inspection. There was a consent form, signed and dated by the client, to a family physician. However, the form was missing an expiration date. Client #2 was admitted into the partial hospitalization level of care on April 23, 2021 and was active at the time of inspection. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date.Client #3 was admitted into the partial hospitalization level of care on April 21, 2021 and was active at the time of inspection. There were consent forms to the funding source and the probation officer, both signed and dated by the client. However, both forms were missing an expiration date.Client #4 was admitted into the partial hospitalization level of care on February 17, 2021 and was discharged February 25, 2021. There were consent forms to the funding source and a physician, both signed and dated by the client. However, both forms were missing an expiration date.Client #5 was admitted into the partial hospitalization level of care on November 27, 2020 and was discharged December 11, 2020. There were consent forms to the funding source and the probation officer, both signed and dated by the client. However, both forms were missing an expiration date.Client #6 was admitted into the partial hospitalization level of care on February 26, 2021 and was discharged March 8, 2021. There were consent forms to the funding source, a physician, and the probation officer, all signed and dated by the client. However, all three forms were missing an expiration date.Client #7 was admitted into the partial hospitalization level of care on September 14, 2020 and was discharged September 24, 2020. There were consent forms to the funding source and the probation officer, both signed and dated by the client. However, both forms were missing an expiration date.Client #8 was admitted into the outpatient level of care on March 15, 2021 and was active at the time of inspection. There were consent forms to a pharmacy and an attorney, both signed and dated by the client. However, both forms were missing an expiration date.Client #9 was admitted into the outpatient level of care on February 23, 2021 and was active at the time of inspection. There were consent forms to the funding source, an outside MH therapist, a physician, and the referral source, all signed and dated by the client. However, all of the forms were missing an expiration date.Client #10 was admitted into the outpatient level of care on March 8, 2021 and was active at the time of inspection. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date.Client #11 was admitted into the outpatient level of care on October 19, 2021 and was discharged March 17, 2021. There were consent forms to the pharmacy, physician, and funding source, all signed and dated by the client. However, all of the forms were missing an expiration date.Client #12 was admitted into the outpatient level of care on September 14, 2021 and was discharged January 22, 2021. There were consent forms to the funding source and the parole officer, both signed and dated by the client. However, both forms were missing an expiration date. Client #13 was admitted into the outpatient level of care on August 20, 2020 and was discharged October 22, 2020. There were consent forms to the funding source, a physician, an attorney, and a pharmacy, all signed and dated by the client. However, all of the forms were missing an expiration date.Client #14 was admitted into the outpatient level of care on February 15, 2021 and was discharged April 22, 2021. There were consent forms to the funding source, another treatment provider, and a pharmacy, all signed and dated by the client. However, all of the forms were missing an expiration date.Client #15 was admitted into the non-hospital detox level of care on May 1, 2021 and was active at the time of inspection. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date. Client #16 was admitted into the non-hospital detox level of care on April 27, 2021 and was active at the time of inspection. There were consent forms to the funding source and a physician, both signed and dated by the client. However, both forms were missing an expiration date.Client #17 was admitted into the non-hospital detox level of care on April 28, 2021 and was active at the time of inspection. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date.Client #18 was admitted into the non-hospital detox level of care on October 27, 2020 and was discharged November 3, 2020. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date.Client #19 was admitted into the non-hospital detox level of care on December 28, 2020 and was discharged January 2, 21. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date.Client #20 was admitted into the non-hospital detox level of care on April 7, 2021 and was discharged April 12, 21. There was a consent form, signed and dated by the client, to a physician. However, the form was missing an expiration date.Client #21 was admitted into the non-hospital detox level of care on April 25, 2021 and was discharged May 1, 21. There were consent forms to the funding source and a physician, both signed and dated by the client. However, both forms were missing an expiration date.Client #22 was admitted into the non-hospital residential level of care on April 12, 2021 and was active at the time of inspection. There was a consent form, signed and dated by the client, to a physician. However, the form was missing an expiration date.Client #23 was admitted into the non-hospital residential level of care on May 1, 2021 and was active at the time of inspection. There were consent forms to the funding source and a physician, both signed and dated by the client. However, both forms were missing an expiration date.Client #24 was admitted into the non-hospital residential level of care on April 6, 2021 and was active at the time of inspection. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date.Client #25 was admitted into the non-hospital residential level of care on January 7, 2021 and was discharged February 27, 2021. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date.Client #26 was admitted into the non-hospital residential level of care on November 30, 2020 and was discharged December 28, 2020. There were consent forms to the funding source and a pharmacy, both signed and dated by the client. However, both forms were missing an expiration date.Client #27 was admitted into the non-hospital residential level of care on January 22, 2021 and was discharged May 15, 2021. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date.Client #28 was admitted into the non-hospital residential level of care on February 3, 2021 and was discharged March 3, 2021. There was a consent form, signed and dated by the client, to the funding source. However, the form was missing an expiration date.The findings were discussed with facility staff during the licensing process.	Plan of Correction The Vice President of Compliance in conjunction with the organizations IT Manager will work to ensure that all consents have a clear indication of expiration. Livengrins IT Manager has updated all consents to include the following: "This form will automatically expire one year from the signature date." All department managers will review consents as part of their routine chart audits to ensure compliance.