INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2025 through March 21, 2025 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:
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of eleven personnel records, the project failed to ensure that a clinical supervisor that has not functioned for two years as a supervisor in the provision of clinical services complete a core curriculum in clinical supervision.
Employee #3 was hired as a clinical supervisor on April 1, 2024, and was current in that position at the time of the inspection. Employee #3 had not functioned for two-years as a supervisor in the provision of clinical services and as of the time of the inspection had not completed a core curriculum in clinical supervision.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical supervisors will complete a core curriculum in clinical supervision within six months of assuming the role. If the DDAP hosted Clinical Supervision Training is unavailable or inaccessible, the clinical supervisor will complete the Relias Academy online training program. The Compliance Assistant will ensure appropriate trainings are assigned via Relias, the Director of Human Resources will ensure compliance.
Employee 3 is attending the supervision training this week 5/12- 5/16/2025.
The Director of Human Resources will ensure compliance by collecting training certificates and reviewing the training tracking spreadsheet periodically to ensure compliance with completion of all required trainings. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of eleven personnel records and staff training records, the project failed to instruct all staff in the use of the fire extinguisher upon employment.
Employee #5 was hired as the counselor on November 16, 2024, and was current in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training until December 18, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All new employees, including rehires, will receive instruction on fire extinguisher use and assigned tasks during emergencies upon employment. The Human Resources Generalist will ensure the appropriate documents are distributed during onboarding, the Director of Human Resources will ensure timely completion. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of eleven personnel records and staff training records, the project failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #5 was hired as the counselor on November 16, 2024, and was current in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this training until December 18, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All new employees, including rehires, will receive instruction on fire extinguisher use and assigned tasks during emergencies upon employment. The Human Resources Generalist will ensure the appropriate documents are distributed during onboarding, the Director of Human Resources will ensure timely completion. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.
Client # 25 was admitted to the inpatient non-hospital level of care on August 19, 2024 and was discharged Against Staff Advice (ASA) on September 12, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
During the most recent supervision, the Director of Residential Services reeducated the team members on the required emergency contact notifications. The Director of Residential Services will perform random chart audits throughout the year to ensure compliance. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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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 that included the specific information to be disclosed in four of twenty-eight client records reviewed.
Client #2 was admitted to the partial hospitalization level of care on February 27, 2025 and was a current client in the partial hospitalization level of care at the time of the inspection. A release of information form for a probation officer, signed by the client on December 11, 2024, did not specify the specific information to be disclosed, it only documented " pertinent information " as information to be disclosed.
Client #9 was admitted to the outpatient level of care on May 1, 2024 and was a current client in the outpatient level of care at the time of the inspection. A release of information form for a primary care physician, signed by the client on January 15, 2025, did not specify the specific information to be disclosed, it only documented " pertinent information " as information to be disclosed.
Client #18 was admitted to the detoxification level of care on November 18, 2024, stepped to the rehabilitation level of care on November 21, 2024 and was discharged from the rehabilitation level of care on December 19, 2024. Two release of information forms for a community service and a recovery house, signed by the client on December 17, 2024, did not specify the specific information to be disclosed, it only documented " facilitate scholarship application " as information to be disclosed.
Client # 28 was transferred to the non-hospital residential level of care on February 24, 2025 and was active at the time of the inspection. The record contained release of information forms to a county agency and a recovery house signed by the client on March 20, 2025, that were missing the specific information to be disclosed.
This is a repeat citation from the March 8, 2024, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During the most recent supervision the Director of Residential Services and Admissions Manager reeducated the team members on the information required on consent forms. The Director of Residential Services and Admission Manager will perform random chart audits throughout the year to ensure compliance. Consents for all active clients have been corrected. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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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 that included the purpose of disclosure in four of twenty-eight client records reviewed.
Client #2 was admitted to the partial hospitalization level of care on February 27, 2025 and was a current client in the partial hospitalization level of care at the time of the inspection. A release of information form for a probation officer, signed by the client on December 11, 2024, did not specify the purpose of disclosure.
Client #3 was admitted to the partial hospitalization level of care on February 18, 2025 and was a current client in the partial hospitalization level of care at the time of the inspection. A release of information form for a mental health provider, signed by the client on January 27, 2025, did not specify the purpose of disclosure.
Client #12 was admitted to the outpatient level of care on August 20, 2024 and was discharged from the outpatient level of care March 11, 2025. A release of information form for a primary care provider, signed by the client on November 22, 2024, did not specify the purpose of disclosure.
Client # 20 was admitted to the non-hospital detoxification level of care on February 27, 2025 and was transferred to the non-hospital residential level of care on March 5, 2025. A consent to release information form to a probation officer that was signed by the client on March 27, 2025, was missing the purpose of disclosure.
This is a repeat citation from the March 8, 2024, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During the most recent staff meeting, Program Manager reeducated the staff on the importance of proper form completion and identifying the information to be disclosed. The Program Manager has also added a column for "forms" in the monthly chart auditing tool. All active client records have been corrected. |
709.63(a)(7) LICENSURE Discharge summary
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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary, in one of one applicable record reviewed.
Client # 17 was admitted on February 24, 2025 and was discharged on March 1, 2025. The record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Director of Residential Services reeducated the team members on the appropriate documentation requirements. The Director of Residential Services will perform random chart audits throughout the year to ensure compliance. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on a review of patient records, the facility failed to ensure that pregnant patients were given the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers, in one applicable record reviewed.
Patient # 23 was transferred to the inpatient non-hospital level of care on May 22, 2024 and was discharged on June 15, 2024. There was no documentation the patient was given the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
During the most recent supervision the Director of Residential Services reeducated the team members on the appropriate documentation requirements. The Director of Residential Services will perform random chart audits throughout the year to ensure compliance. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on an observation of medication administration on March 20, 2025, the dispensing nurse was observed to be looking at a computer monitor instead of observing the patient when ingesting the agent at 09:07 a.m. and 09:24 a.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During supervision the Nurse Manager reeducated nursing staff on the appropriate observation practices. Nurse Manager will perform random observations of medication administration. |
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:
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Observations
Based on the review of outpatient client records, the project failed to develop an individual treatment and rehabilitation plan with the client in three of seven client records reviewed.
Client #8 was admitted on June 4, 2024 and was active at the time of the inspection. A treatment and rehabilitation plan was documented in the record on June 4, 2024; however, it was not documented that it was developed with the client until it was signed on July 30, 2024.
Client #12 was admitted on August 20, 2024 and was discharged on March 11, 2025. A treatment and rehabilitation plan was documented in the record on August 20, 2024; however, it was not documented that it was developed with the client until it was signed on September 3, 2024.
Client #14 was admitted on May 16, 2024 and was discharged on March 11, 2025. A treatment and rehabilitation plan was documented in the record on May 16, 2024; however, it was not documented that it was developed with the client until it was signed on July 30, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Manager has reeducated staff on the proper documentation procedure and the importance of signing the treatment plan on time and with the client present. The Director of Residential Services will perform random chart audits throughout the year to ensure compliance.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in five of seven records reviewed.
Client #8 was admitted on June 4, 2024 and was active at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on September 27, 2024, and the next update was due no later than November 27, 2024; however, an updated treatment plan was not documented in the record at the time of the inspection.
Client #9 was admitted on May 1, 2024 and was a current client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on July 15, 2024, and the next update was due no later than September 15, 2024; however, the updated treatment plan was not documented in the record until October 14, 2024.
Client #10 was admitted on May 9, 2024 and was a current client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on July 9, 2024, and the next update was due no later than September 9, 2024; however, the updated treatment plan was not documented in the record until November 22, 2024.
Client #12 was admitted on August 20, 2024 and was discharged on March 11, 2025. An updated treatment and rehabilitation plan was documented in the record on January 2, 2025, and the next update was due no later than March 2, 2025; however, an updated treatment plan was not documented in the record at the time of the inspection.
Client # 14 was admitted on May 16, 2024 and was discharged on March 11, 2025. An updated treatment and rehabilitation plan was documented in the record on November 26, 2024, and the next update was due no later than January 26, 2025; however, the updated treatment plan was not documented in the record until February 25, 2025.
This is a repeat citation from the March 8, 2024, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Manager has reeducated staff on the importance of timely treatment plans and treatment plan updates. The Director of Residential Services will perform random chart audits throughout the year to ensure compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in four of seven applicable client records reviewed.
Client #8 was admitted on June 4, 2024 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on June 4, 2024, indicated that the client was to receive one individual counseling session and one group counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of June 9, 2024 through June 15, 2024, June 16, 2024 through June 22, 2024, June 23, 2024 through June 29, 2024 and for the months of July and August. Additionally, there were no group session documented in the client record for the weeks of June 9, 2024 through June 15, 2024, June 16, 2024 through June 22, 2024, June 23, 2024 through June 29, 2024 and for the month of July.
Client #9 was admitted on May 1, 2024 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on April 1, 2024, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the client record for the months of June 2024, August 2024, September 2024, October 2024, November 2024 and January 2025.
Client #10 was admitted on May 9, 2024 and was a current client at the time of the inspection. An updated treatment and rehabilitation plan, documented in the client record on July 9, 2024, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the client record for the months of November 2024, January 2025 and February 2025.
Client # 14 was admitted on May 16, 2024 and was discharged on March 11, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on May 16, 2024, indicated that the client was to receive one group counseling session per week; however, there were no group counseling sessions documented in the client record for the weeks of July 14, 2024 through July 20, 2024, July 28, 2024 through August 3, 2024, August 11, 2024 through August 17, 2024, September 15, 2024 through September 21, 2024, October 13, 2024 through October 19, 2024, October 20, 2024 through October 26, 2024, December 29, 2024 through January 4, 2025, January 5, 2025 through January 11, 2025, January 12, 2025 through January 18, 2025, and January 19, 2025 through January 25, 2025. Additionally, there were no group counseling sessions documented in the client record for the months of November 2024, December 2024 and February 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Manager has reeducated staff on the proper documentation procedure for missed services and the importance of treatment plan services matching the services provided. The Program Manager will perform random chart audits throughout the year to ensure compliance. |