INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 10, 2026 through March 13, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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
|
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.
|
Observations
Based on a review of personnel records, the project failed to ensure that six of fourteen employees received a minimum of six hours of HIV/AIDS and four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.Employee # 6 was hired as a counselor on November 13, 2024 and was currently in that position at the time of the inspection. Employee #6 was due to have the communicable disease training no later than November 13, 2025. Documentation showed that this employee did not receive the six hours of TB/STD training until January 8, 2026.Employee # 7 was hired as a counselor on August 26, 2024 and was currently in that position at the time of the inspection. Employee #6 was due to have the communicable disease training no later than August 26, 2025. Documentation showed that this employee did not receive the six hours of TB/STD training at the time of the inspection.Employee # 11 was hired as a behavioral health technician on July 17, 2023 and was currently in that position at the time of the inspection. Employee #11 was due to have the communicable disease training no later than July 17, 2025. Documentation showed that this employee did not receive the six hours of TB/STD training until January 8, 2026.Employee # 12 was hired as a behavioral health technician on February 21, 2023 and was currently in that position at the time of the inspection. Employee #12 was due to have the communicable disease training no later than February 21, 2025. Documentation showed that this employee did not receive the six hours of HIV/AID training until October 16, 2025.Employee # 13 was hired as a behavioral health technician on January 27, 2023 and was currently in that position at the time of the inspection. Employee #13 was due to have the communicable disease training no later than January 27, 2025. Documentation showed that this employee did not receive the six hours of HIV/AID training until March 16, 2025, and there was no documentation that the employee received the four hours of TB/STD training at the time of the inspection.Employee # 14 was hired as a behavioral health technician on August 26, 2023 and was currently in that position at the time of the inspection. Employee #14 was due to have the communicable disease training no later than August 26, 2025. Documentation showed that this employee did not receive the six hours of HIV/AID training until October 30, 2025, and there was no documentation that the employee received the four hours of TB/STD training at the time of the inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Employees #7, #12, and #13 are scheduled for training on June 29, 2026. Employees #6 and #11 completed their training late on January 8, 2026. Employee #14 is compliant, having completed HIV training on October 16, 2024, and TB/STD/Hepatitis training on November 20, 2024; however, documentation was not provided at the time due to an oversight.
Moving forward, the Director of Human Resources will ensure that new employees are enrolled in training promptly to prevent future citations. Compliance will be monitored through a tracking system. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on a physical plant inspection on March 12, 2026, the facility failed to ventilate toilet and washrooms by exhaust fan or window.The exhaust fans in the bathrooms for rooms 104 and 208 in G House were not functioning and there was no window in that bathroom to provide ventilation.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Director of Facilities replaced the nonfunctioning exhaust fans in question before the close of the survey.
The maintenance team will conduct regular checks to ensure all equipment is working properly. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical plant inspection on March 12, 2026, the facility failed to ensure fire extinguishers are inspected and approved annually by local fire department or fire extinguisher company.The fire extinguisher in the lower-level group room was last inspected October of 2024.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Prior to the close of the survey the Director of Facilities replaced the outdated extinguisher.
During regular checks, the maintenance team will ensure that all fire extinguishers are up to date.
|
709.28 (c) 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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of twenty-eight records reviewed.Client #24 was admitted on February 13, 2026 and was active at the time of the inspection. A family session was held with a family member on March 11, 2026; however, there was no release of information documented in the record prior to the family member participating in the family session.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 3/25/2026, during Supervision, The Director of Residential Services, Program Manager and Admissions Manager reeducated the team members on the information required on consent forms. The Director of Residential Services, Program Manager, and Admission Manager will perform random chart audits throughout the year to ensure compliance. Consents for all active clients have been updated. |
709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
|
Observations
Based on a review of partial hospitalization client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within twenty-four hours of the date of service, per the facility's policy, in five of seven records reviewed. Client #15 was admitted on October 7, 2025 and was discharged on November 11, 2025. The record contained progress notes for an individual counseling session occurring on October 10, 2025, October 28, 2025, November 3, 2025, and November 6, 2025, that were not documented in the record until November 11, 2025, January 30, 2026, November 11, 2025, and March 10, 2026, respectively. Additionally, the record contained a progress note for a group counseling session occurring on November 4, 2025, and November 6, 2025, that was not documented in the record until January 30, 2026, and March 9, 2026, respectively.Client #17 was admitted on September 16, 2025 and was discharged on October 9, 2025. The record contained progress notes for an individual counseling session occurring on September 16, 2025, and September 22, 2026 that were not documented in the record until January 30, 2026 and December 8, 2025, respectively. Client #18 was admitted on June 2, 2025 and was discharged on June 30, 2025. The record contained progress notes for an individual counseling session occurring on June 6, 2025, June 11, 2025, June 27, 2025, and June 30, 2025, that were not documented in the record until July 11, 2025, respectively. Client #20 was admitted on February 18, 2026 and was active at the time of the inspection. The record contained progress notes for an individual counseling session occurring on February 18, 2026, February 20, 2026, February 24, 2026, and February 27, 2026, that were not documented in the record until March 10, 2026, respectively. Client #21 was admitted on December 1, 2025 and was active at the time of the inspection. The record contained progress notes for an individual counseling session occurring on December 10, 2025, December 15, 2025, December 19, 2025, December 23, 2025, December 30, 2025, December 31, 2025, January 12, 2026, January 14, 2026, January 19, 2026, January 21, 2026, February 17, 2026 and January 19, 2026, that were not documented in the record until March 10, 2026, respectively. These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 3/25/2026, during supervision, the team members were re-educated on the proper documentation protocols. The Director of Residential Services and Program Manager has added this to the audit checklist and will monitor during monthly chart audit completion. Director of Residential Services and Program Manager will address issues of noncompliance during individual supervision. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
|
Observations
Based on the review of short-term detoxification client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included a follow-up contact note within thirty days of discharge, per facility policy, in two of four applicable client records reviewed.Client #1 was admitted on November 10, 2025 and was discharged on November 16, 2025. A follow-up contact note was not documented in the record until February 16, 2026.Client #4 was admitted on July 6, 2025 and was discharged on July 11, 2025. A follow-up contact note was not documented in the record until September 5, 2026.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 3/25/2026, during supervision, the team members were re-educated on the proper documentation protocols. Program Manager and Director of Residential Services will review regularly to ensure follow up calls are completed in a timely manner.
Audits will be conducted to ensure follow-up calls are made within the timeframe outlined in the facility policy. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on the review of residential treatment and rehabilitation client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included a follow-up contact note within thirty days of discharge, per facility policy, in two of four applicable client records reviewed.Client #8 was admitted on December 11, 2025 and was discharged on December 23, 2025. A follow-up contact note was not documented in the record until February 2, 2026.Client #9 was admitted on May 23, 2025 and was discharged on June 26, 2025. A follow-up contact note was not documented in the record until August 13, 2026.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 3/25/2026, during supervision, the team members were re-educated on the proper documentation protocols. Program Manager and Director of Residential Services will review regularly to ensure follow up calls are completed in a timely manner.
Audits will be conducted to ensure follow-up calls are made within the timeframe outlined in the facility policy. |
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
Based on the review of outpatient client records, the facility's policy and procedure manual, the project failed to develop an individual treatment and rehabilitation plan with the client, within seven days of admission, per facility policy, in four of seven client records reviewed.Client #22 was admitted on February 23, 2026 and was active at the time of the inspection. A treatment and rehabilitation plan was not documented in the record or developed with the client until March 5, 2026. Client #23 was admitted on February 2, 2026 and was discharged on March 9, 2026. A treatment and rehabilitation plan was not documented in the record or developed with the client.Client #27 was admitted on January 15, 2026 and was discharged on February 17, 2026. A treatment and rehabilitation plan was not documented in the record or developed with the client until February 5, 2026. Client #28 was admitted on November 14, 2025 and was discharged on February 11, 2026. A treatment and rehabilitation plan was not documented in the record or developed with the client.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On March 25, 2026, during supervision, team members were re-educated on proper documentation protocols, with an emphasis on completing treatment plans in collaboration with clients and incorporating their input. To support compliance, the Director of Residential Services and the Program Manager have added this requirement to the audit checklist and will monitor adherence during monthly chart audits. Any instances of noncompliance will be addressed during individual supervision sessions with the Director of Residential Services and the Program Manager. |
709.93(a)(10) LICENSURE Client records
709.93. 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.
|
Observations
Based on the review of outpatient client records, the facility's policy and procedure manual, the project failed to document a discharge summary, within seven days post discharge, per facility policy, in two of four applicable client records reviewed.Client #27 was admitted on January 15, 2026 and was discharged on February 17, 2026. A discharge summary was not documented in the record at the time of the inspection.Client #28 was admitted on November 14, 2025 and was discharged on February 11, 2026. A discharge summary was not documented in the record at the time of the inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 3/25/2026, during supervision, the team members were re-educated on the proper documentation protocols. The Director of Residential Services and Program Manager has added this to the audit checklist and will monitor during monthly chart audit completion. Director of Residential Services and Program Manager will address issues of noncompliance during individual supervision. |