INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 12, 2012 licensure renewal inspection. The follow-up inspection was conducted on September 24 through 26, 2012 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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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.
The findings include:
Four partial hospitalization client records requiring documentation of psychosocial evaluations were reviewed on September 25, 2012, 2012, records # 18, 19, 20, 21 and 22. The facility failed to document a psychosocial evaluation that included an evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment and the counselor conclusion/impression of the client in four of four records reviewed,# 18, 19, 20, 21 and 22 .
An interview with facility staff on September 26, 2012 confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on 3/12/12.
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Plan of Correction
In a meeting on 10/10/12, the program manager reminded all counselors that the psychosocial evaluation needs to include evaluation of the patient's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment. The program manager will randomly monitor patient charts on a monthly basis to ensure compliance. The quality assistant will also randomly monitor patient charts on a monthly basis to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.62(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 a physical examinations in accordance with facility policy.
The findings include:
Per the facility's policy and the 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.
Eight short term detoxification client records were reviewed on September 25, 2012 for physical examinations, records, #1, 2, 3, 4, 5, 6, 7 and 8. The facility failed to document physical examinations that included the client's vital signs in eight out of eight client records reviewed #1, 2,, 3, 4, 5, 6, 7, and 8.
An interview with facility staff on September 26, 2012 confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on 3/12/12.
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Plan of Correction
On 10/23/12 the Clinical/Nursing Director revised the History and Physical Form to include vital signs. In a meeting on 10/23/12, the Clinical/Nursing Director informed all Medical Staff of the revision to include vital signs on the History and Physical Form. The Quality Assistant will randomly monitor patient charts on a monthly basis. 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 physical examinations in accordance with facility policy.
The findings include:
Per the facility's policy and the 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.
Four residential treatment and rehabilitation client records were reviewed on September 25, 2012, records, #9, 10, 11 and 12. The facility failed to document physical examinations that included the client's vital signs in four out of four client records reviewed #9, 10, 11 and 12.
An interview with facility staff on September 26, 2012 confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on 3/12/12.
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Plan of Correction
On 10/23/12 the Clinica/Nursing Director revised the History and Physical Evaluation to include vital signs. In a meeting on 10/23/12, the Clinical/Nursing Director informed all Medical Staff of the revision to include vital signs to the History and Physcial Evaluation. The Quality Assistant will randomly monitor patient charts on a monthly basis. 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.
The findings include:
Four residential treatment and rehabilitation client records requiring documentation of psychosocial evaluations were reviewed on September 25, 2012, 2012, records # 9, 10, 11 and 12. The facility failed to document a psychosocial evaluation that included an evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment and the counselor conclusion/impression of the client in four of four records reviewed, # 9, 10, 11 and 12. .
An interview with facility staff on September 26, 2012 confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on 3/12/12.
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Plan of Correction
In a meeting on 10/10/12, the Program Manager reminded all counselors that the psychosocial evaluation needs to include evaluation of the patient's assest/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment and the counselor conclusion/impression of the patient. The Program Manager will randomly monitor patient charts on a monthly basis to ensure compliance. The Quality Assistant will also monitor patient charts on a monthly basis 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 accordance with facility policy.
The findings include:
Per the facility's policy discharge summaries are required within 7 days of the clients discharge date. Discharge summaries are to include the client's reason for treatment, services offered by the facility, the client's response to treatment and the clients status at discharge.
Four residential rehabilitation client records requiring documentation of discharge summaries were reviewed on September 26, 2012. The facility failed to document a discharge summary that included the client's reason for treatment and the client's status at the time of discharge in one of four records reviewed, # 16.
An interview with facility staff on September 26, 2012 confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on 3/12/12.
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Plan of Correction
In a meeting on 10/10/12, the Program Manager reminded all counselors that Discharge Summaries need to include the patient's reason for treatment and the patient's status at the time of discharge. The Program Manager will randomly monitor patient charts on a monthly basis to ensure compliance. The Quality Assistant will also randomly monitor patient charts on a monthly basis to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |