This report is a result of an on-site unusual incident review conducted on July 29, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, 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 investigation:
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Plan of Correction
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Observations
Based on a review of the facility's residential rehab policies and procedures, client records and a review of facility security footage, the facility failed to follow their policy and procedures manual to ensure that rounds were completed every sixty minutes.
DDAP staff reviewed facility rounding sheets for July 26, 2026, these documents indicate that rounds were completed hourly at Building G between the hours of 7:00 am and 5pm; however, a review of facility video security footage revealed that rounding was not completed between the hours of 1:00-2:00pm and 3:00-4:00pm.
This finding was reviewed with facility staff during the unusual incident review.
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Plan of Correction
The Patient Rounds Policy has been revised to clearly define required observation expectations and documentation standards. Standardized competency validation will be implemented for staff responsible for patient observations, including review and acknowledgement of observation requirements, roll-call expectations, documentation standards, and required escalation procedures. Progressive accountability will be implemented for inaccurate documentation in accordance with established Human Resources policies and practices. Additionally, the CEO orientation segment will be enhanced to reinforce ethical documentation, personal accountability, and the importance of accurately completing required patient observations.
To ensure ongoing compliance and prevent recurrence, the Behavioral Health Technician Supervisor will conduct monthly audits of Behavioral Health Technician documentation and patient rounding practices. The audit will include review of Patient Records of Service for completeness and accuracy, review of patient rounding sheets to ensure required rounds are appropriately documented, and validation that rounds are being completed in accordance with facility policy and established observation requirements.
To ensure ongoing compliance and prevent recurrence, the Behavioral Health Technician Supervisor will conduct monthly audits of Behavioral Health Technician documentation and patient rounding practices. The audit will include review of Patient Records of Service for completeness and accuracy, review of patient rounding sheets to ensure required rounds are appropriately documented, and validation that rounds are being completed in accordance with facility policy and established observation requirements.
Results of the monthly audits will be documented and submitted to the Director of Residential Services and the Compliance Department for review. Any deficiencies identified through the audit process will result in appropriate corrective action, which may include staff re-education, additional competency validation, supervision, and/or progressive disciplinary action as indicated. Identified trends will be reviewed to determine whether additional system or policy changes are necessary.
The monthly auditing process will remain an ongoing quality assurance measure to ensure sustained compliance with patient observation and documentation requirements.
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