INITIAL COMMENTS
|
This report is a result of an on-site provisional license follow-up inspection conducted on October 5, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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
|
709.28 (c) (5) 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:
(5) Dated signature of witness.
|
Observations
The facility failed to ensure that all informed and voluntary consent to release information forms documented the dated signature of the witness at the same time of the client signature on release of information forms in one of twenty-five client records reviewed.Client # 18 was admitted to the partial hospitalization activity on September 21, 2020 and was still active at the time of the inspection. Release of information forms to another treatment provider, a lawyer, the funding source, a family member and a short-term disability provider were all signed by the client on September 18, 2020; however, all of the consent forms were not signed by the witness until September 25, 2020.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility has migrated to a new EMR system, this system currently permits staff to save consents without obtaining dual signature. The facility will be changing that option in the EMR to no longer permit the consent from being saved without dual signature. Additionally, the Director of Admissions will be reviewing consents on a regular basis to ensure proper completion and dual signatures. All active client charts have been updated.
|
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
|
Observations
The facility failed to ensure that an individual treatment and rehabilitation plan, developed with the client, included the frequency of treatment and rehabilitation services in two of five applicable client records reviewed.Client # 16 was admitted to the partial hospitalization activity on September 21, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was signed by the client on September 25, 2020 but did not include the frequency of treatment and rehabilitation services.Client # 17 was admitted to the partial hospitalization activity on September 17, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was signed by the client on September 22, 2020 but did not include the frequency of treatment and rehabilitation services.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Manager has reviewed the documenation requirements for individual treatment plans, including the need for type and frequesncy of service, with staff during weekly staff meeting. Program Managers are pulling reports to address compliance of treatment planning and treatment plan updating on a routine basis with staff. The Program Manager and Director of Residential Services will continue to monitor chart compliance monthly using a random sample. The sample size will be increased from 5 charts per month to 10 charts per month. Any clinician failing to maintain chart compliance may be subject to corrective action.
The treatment plans for all mentioned clients have been corrected.
|
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
|
Observations
The facility failed to ensure that a narcotic treatment physician or a designated qualified mid-level practitioner conducted the face-to-face determination with a client to determine the current dependency and 1 year history of dependence in one of three applicable records reviewed.At the time of the inspection, the facility has a DDAP-approved exception to allow mid-level practitioners to diagnose, admit, and prescribe buprenorphine in a licensed treatment facility. However, the approval was granted on the condition that the facility only utilize mid-level practitioners that are DATA 2000 waived from SAMHSA's Center for Substance Abuse Treatment (CSAT).Client #5 was admitted to the detoxification level of care on August 26, 2020 and was discharged on August 31, 2020. The face to face determination and current dependency was completed by a non-DATA waived CRNP on August 27, 2020.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The referenced mid-level practitioner does hold the necessary Data 2000 waiver (AKA X Waiver). The facility did not have the most current DEA card in the agencies file at the time of inspection. The aforementioned license number can be provided is necessary. Moving forward the facilities Human resources department will be keeping a detailed file for all agency nurses and nurse practitioners to ensure the most current documents are available. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
|
Observations
The facility failed to ensure that individual treatment and rehabilitation plans, developed with the client, include the frequency of treatment and rehabilitation services in two of four applicable client records reviewed.Client # 22 was admitted to the outpatient activity on August 31, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was signed by the client on September 9, 2020 but did not include the frequency of treatment and rehabilitation services. Client # 23 was admitted to the outpatient activity on August 17, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was signed by the client on September 22, 2020 but did not include the frequency of treatment and rehabilitation services.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Manager has reviewed the documentation requirements for individual treatment plans, including the need for type and frequency of service, with staff during weekly staff meeting. Program Managers are pulling reports to address compliance of treatment planning and treatment plan updating on a routine basis with staff. The Program Manager and Director of Residential Services will continue to monitor chart compliance monthly using a random sample. The sample size will be increased from 5 charts per month to 10 charts per month. Any clinician failing to maintain chart compliance may be subject to corrective action.
The treatment plans for all mentioned clients have been corrected.
|