INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 2016 by staff from the Division of Drug and Alcohol 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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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to demonstrate that all clients were informed of all their rights in eight of eight client records reviewed.
The findings include:
Eight client records requiring documentation of client rights notification were reviewed on January 27, 2016. The facility failed to document that clients # 1, 2, 3, 4, 5, 6, 7, and 8 were informed of their rights by providing a written acknowledgment in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client rights forms were signed wherever possible (in active patient charts). The importance of signing client rights forms was shared with the offending clinical staff and office managers. The identified staff members are required to attend an upcoming offering of the Clinical Documentation Compliance 101 training on February 25, 2016. The Quality Assurance Manager will be responsible for the ongoing monitoring of client rights form compliance. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project as part of the intake procedure in three of eight client records.
The findings include:
Eight client records were reviewed on January 27, 2016 for documentation of a client orientation.
Client #1 was admitted to the facility on September 21, 2015 and was discharged on December 14, 2015. There was no documentation of client orientation in the client record.
Client #3 was admitted to the facility on November 12, 2015 and was discharged on January 7, 2015. There was no documentation of client orientation in the client record.
Client #6 was admitted to the facility on December 14, 2015 and was an active client at the time of the inspection. There was no documentation of client orientation in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Orientation was provided and documented by the clinician wherever possible (in active patient charts). The importance of documenting orientation was shared with the offending clinical staff. The identified staff members are required to attend an upcoming offering of the Clinical Documentation Compliance 101 training on February 25, 2016, which will highlight orientation requirements. The Quality Assurance Manager will be responsible for the ongoing monitoring of orientation documentation compliance. |
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 a review of client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in eight of eight outpatient activity client records.
The findings include:
Eight outpatient activity client records were reviewed on January 27, 2016. All were reviewed for individualized treatment and rehabilitation plans which are to be developed with the client. Client records # 1 through 8 did not contain an individualized treatment and rehabilitation plan that was developed with the client.
Client #1 was admitted on September 21, 2015 and their was no evidence that an individualized treatment and rehabilitation plan was developed.
Client #2 was admitted on June 10, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on June 12, 2015. The treatment plan was not signed by the client.
Client #3 was admitted on November 12, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on November 17, 2015. The treatment plan was not signed by the client.
Client #4 was admitted on September 17, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on October 22, 2015. The treatment plan was not signed by the client.
Client #5 was admitted on July 23, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on October 15, 2015. The treatment plan was not signed by the client.
Client #6 was admitted on December 14, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on January 19, 2016. The treatment plan was not signed by the client.
Client #7 was admitted on November 25, 2015 and their was no indication that an individualized treatment and rehabilitation plan was developed.
Client #8 was admitted on December 1, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on January 19, 2016. The treatment plan was not signed by the client
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans were updated and signed wherever possible (in active patient charts). The importance of timely and quality treatment plans was shared with the offending clinical staff. The identified staff members are required to attend an upcoming offering of the Clinical Documentation Compliance 101 training on February 25, 2016, which will focus on treatment planning. The Quality Assurance Manager will be responsible for the ongoing monitoring of treatment plan compliance. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record which included case consultations and aftercare plans, in three of eight client records.
The findings include:
Eight client records requiring documentation of case consultations for discharged clients were reviewed January 27, 2016. The facility failed to document a case consultation in discharged client records, #2 and 5.
Additionall, the facility failed to document an aftercare plan in discharged client records, #2, 4 and 5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The importance of case consultations and discharge documentation was shared with the offending clinical staff. The identified staff members are required to attend an upcoming offering of the Clinical Documentation Compliance 101 training on February 25, 2016, which will focus on case consultations and discharge documentation requirements. The Quality Assurance Manager will be responsible for the ongoing monitoring of case consultation and discharge documentation compliance. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment and rehabilitation plans for medical assistance clients as required.
The findings included:
Eight client records were reviewed on January 27, 2015. One of eight client records was required to have a physician signature on the individual treatment and rehabilitation plan.
Client #3 was admitted to outpatient treatment on November 12, 2015. The individual treatment and rehabilitation plan was developed on November 17, 2015 and did not include a physician signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The physician signed the treatment plan wherever possible (in active patient charts). The importance of sending treatment plans of medical assistance patients for the Medical Directors signature was shared with the offending clinical staff. The identified staff members are required to attend an upcoming offering of the Clinical Documentation Compliance 101 training on February 25, 2016, which will focus on this requirement. The Quality Assurance Manager will be responsible for ongoing monitoring. |