INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 11, 2011 licensure renewal inspection. The follow-up inspection was conducted on September 13, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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(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 review of personnel records, the facility failed to ensure that the project director completed 12 clock hours of required training in one of one personnel record reviewed.
The findings include:
On September 13, 2011, one personnel record was reviewed for documentation of the required 12 clock hours of training for the project director. The facility failed to document 12 clock hours of training in personnel record # 1.
Employee # 1, the project director, was hired on October 26, 1987. The facility's training year is from July 1, 2010 to June 30, 2011. Employee # 1's personnel record only had documentation of 5 clock hours of training for the July 1, 2010 to June 30, 2011 training year as of September 13, 2011.
During an ongoing dialogue with the quality assurance manger conducted on September 13, 2011 from approximately 1:00 P.M. to 1:30 P.M., the findings were confirmed.
This is a repeat citation. The facility was cited on February 11, 2011 for noncompliance with this standard.
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Plan of Correction
The Director, Total Quality Management will remind the Project Director of the need to obtain twelve training hours for each training year. The Director, Total Quality Management will monitor compliance on a monthly basis. If the requirement 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. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 an individual treatment and rehabilitation plan with the client upon the completion of the psychosocial evaluation and/or in acordance with facility policy.
The findings include:
The facility's policy titled: "Treatment Planning," states:
"Primary Counselor (Case Manager)
1.Review the entire clinical record along with all the assessment tools.
2. On or before the seventh day of treatment (or by the third day of treatment for patients enrolled in Dual Diagnosis Program), formulate the Master Treatment Plan utilizing the preliminary treatment plan and input from all disciplines and the patient, identifying how the patient is involved in the treatment planning process."
On September 13, 2011, nine records were reviewed for documentation of individual treatment and rehabilitation plan. The facility did not document the individual treatment and rehabilitation plan in accordance with the facility's policies and procedures on treatment planning in client records # 1 and 9. Also, the facility did not document and individual treatment and rehabilitation plan upon the completion of the psychosocial evaluation in client record # 5.
Client # 1 was admitted August 23, 2011. The psychosocial evaluation was completed on September 1, 2011; however, the individual treatment plan was completed on August 29, 2011.
Client # 5 was admitted August 25, 2011. The individual treatment plan was due September 1, 2011 but the individual treatment plan was not completed until September 5, 2011.
Client # 9 was admitted August 24, 2011. The psychosocial evaluation was completed on September 1, 2011; however, the individual treatment plan was completed on August 30, 2011.
During an ongoing dialogue with the quality assurance manager conducted on September 13, 2011 from approximately 3:00 P.M. to 3:30 P.M., the findings were confirmed.
This is a repeat citation. The facility was cited on February 11, 2011 on individual treatment and rehabilitation plans.
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Plan of Correction
In a meeting, on 10/24/11, the Program Manager will remind all counselors of the need to complete Treatment Plans for all patients, by the seventh day of treatment. The Program Manager will also remind all counselors that the Psychosocial Evaluation needs to be completed prior to the Treatment Plan. The Program Manager will randomly monitor patient charts on a monthly basis, to ensure compliance. Oversight will be provided by the Director of Residential Services. The QA Assistant will also randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services in six of nine records reviewed.
The findings include:
On September 13, 2011, nine client records were reviewed for documentation of frequency of treatment and rehabilitation services. The facility did not document the frequency of treatment and rehabilitation services in six of nine records reviewed, specifically,client records # 1, 2, 3, 4, 5, and 9.
Client # 1 was admitted August 23, 2011. The individual treatment and rehabilitation plan was completed on August 29, 2011, but did not include the frequency of treatment and rehabilitation services.
Client # 2 was admitted August 23, 2011. The individual treatment and rehabilitation plan was completed on August 27, 2011, but did not include the frequency of treatment and rehabilitation services.
Client # 3 was admitted August 25, 2011. The individual treatment and rehabilitation plan was completed on August 31, 2011, but did not include the frequency of treatment and rehabilitation services.
Client # 4 was admitted August 22, 2011. The individual treatment and rehabilitation plan was completed on September 1, 2011, but did not include the frequency of treatment and rehabilitation services.
Client # 5 was admitted August 25, 2011. The individual treatment and rehabilitation plan was completed on September 5, 2011, but did not include the frequency of treatment and rehabilitation services.
Client # 9 was admitted August 24, 2011. The individual treatment and rehabilitation plan was completed on August 30, 2011, but did not include the frequency of treatment and rehabilitation services.
During an ongoing dialogue with the quality assurance manager conducted on September 13, 2011 from approximately 3:00 P.M. to 3:30 P.M., the findings were confirmed.
This is a repeat citation. The facility was cited on February 11, 2011 for noncompliance with this standard.
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Plan of Correction
In a meeting, on 10/24/11, the Program Manager will remind all counselors of the need to include type and frequency of services in Treatment Plans 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 of Residential Services. The QA Assistant will also monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |