INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 2017 through March 8, 2017 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, the facility failed to provide documentation of an individual training plan for employee # 1 and employee # 2.
Employee # 1 was hired as the Project Director on 10/26/87. There was no documentation of an individual training plan for the current year, which was identified as 07/01/16- 06/30/17.
Employee # 2 was hired as the Facility Director on 09/03/01. There was no documentation of an individual training plan for the current year, which was identified as 07/01/16- 06/30/17.
These findings were reviewed 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 3/15/17, the Vice President of Human Resources reached out to management regarding the the importance of timely reviews. All outstanding reviews and training plans have since been submitted. The VP of HR will continue to track outstanding performance reviews. |
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 completed between 03/07/17 and 03/08/17, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in personnel record # ' s 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25.
Employee #15 was hired as a dining services staff on 07/01/14. Employee #15 was due to complete the required HIV/AIDS training no later than 07/01/16. There was no documentation in the employee file indicating that the employee received HIV/AIDS training as of the date of the inspection.
Employee #16 was hired as a FRAT Unit Director on 01/06/14. Employee #16 was due to complete the required HIV/AIDS training and the TB/STD training no later than 01/06/16. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #17 was hired as a FRAT Unit Director on 06/17/11. Employee #17 was due to complete the TB/STD training no later than 06/17/13. There was no documentation in the employee file indicating that the employee received the TB/STD training as of the date of the inspection.
Employee #18 was hired as a staff technician on 08/05/11. Employee #18 was due to complete the required HIV/AIDS training and the TB/STD training no later than 08/05/13. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #19 was hired as a staff technician on 08/27/12. Employee #19 was due to complete the TB/STD training no later than 08/27/14. There was no documentation in the employee file indicating that the employee received the TB/STD training as of the date of the inspection.
Employee #20 was hired as a staff technician on 8/27/12. Employee #20 was due to complete the required TB/STD training no later than 08/27/14. There was no documentation in the employee file indicating that the employee received TB/STD training as of the date of the inspection.
Employee #21 was hired as a staff technician on 11/20/13. Employee #21 was due to complete the required TB/STD training no later than 11/20/15. There was no documentation in the employee file indicating that the employee received TB/STD training as of the date of the inspection.
Employee #22 was hired as a staff technician on 09/06/14. Employee #22 was due to complete the required HIV/AIDS training and the TB/STD training no later than 09/06/16. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #23 was hired as a maintenance staff on 11/18/13. Employee #23 was due to complete the required HIV/AIDS training and the TB/STD training no later than 11/18/15. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #24 was hired as a call center staff on 04/09/14. Employee #24 was due to complete the required HIV/AIDS training no later than 04/09/16. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training as of the date of the inspection.
Employee #25 was hired as a financial counselor on 01/30/12. Employee #25 was due to complete the required the TB/STD training no later than 01/30/14. There was no documentation in the employee file indicating that the employee received the TB/STD training as of the date of the inspection.
These findings were reviewed 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 or find their own HIV/AIDs training externally, based on their needs. Staff have been provided supervision on importance of attending required trainings.
This is to be monitored by the Education Coordinator moving forward. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection on 03/08/17 at approximately 01:15 P.M., the facility failed to ensure that all heaters in the facility were permanently mounted or installed. A space heater was found in the closet of room 002 of the E house.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The heater in question was brought into the facility unauthorized. Staff were reminded of expectation and policy in an email on 3/15/17. Facilities director to continue to monitor compliance.
The heater was removed. |
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 on 03/07/17 and 03/08/17, the facility failed to ensure that personnel records contained documentation of an annual written individual performance evaluation in employee record # ' s 1, 2, and 10.
Employee # 1 was hired as the Project Director on 10/26/87. There was no documentation of an annual employee evaluation since the last inspection.
Employee # 2 was hired as the Facility Director on 09/03/01. There was no documentation of an annual employee evaluation since the last inspection.
Employee # 10 was hired as a counselor on 10/04/14. There was no documentation of an annual employee evaluation since the last inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/15/17, the Vice President of Human Resources reached out to management regarding the the importance of timely reviews. All outstanding reviews have since been submitted. The VP of HR will continue to track outstanding performance reviews. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, records for client #'s 13, 14, and 15 had treatment plan updates that were missing at the time of the inspection.
Client #13 was admitted on 02/15/17 and was an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on 02/13/17 and the next update was due no later than 02/27/17; however, no update was completed by the time of the inspection.
Client #14 was admitted on 02/17/17 and was an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on 02/17/17 and the treatment plan update was due no later than 03/03/17; however, no update was completed by the time of the inspection.
Client #15 was admitted on 02/18/17 and was an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on 02/18/17 and the treatment plan update was due no later than 03/04/17; however, no update was completed by the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff responsible for documentation infractions will be required to attend a clinical documentation training refresher course on 4/20/17 that will focus on treatment planning. Director of Quality Assurance will continue to monitor documentation compliance.
Treatment plan updates were completed for the clients in question by 3/10/17. |