INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 02, 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:
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Plan of Correction
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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:
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Observations
Based on a review of partial hospitalization client records, the facility failed to ensure written documentation that individual treatment and rehabilitation plans were developed with the client, within seven days of admission per facility policy, in four out of seven records reviewed.
Client #16 was admitted on January 15, 2026, and still active at the time of inspection. A treatment and rehabilitation plan was due to be completed by January 22, 2026; however, there was no written documentation it was developed with the client until January 28, 2026.
Client #17 was admitted on February 18, 2026, and still active at time of inspection. A treatment and rehabilitation plan was due to be completed by February 25, 2026; however, there was no written documentation it was developed with the client until February 27, 2026.
Client #18 was admitted on February 02, 2026, and still active at time of inspection. A treatment and rehabilitation plan was due to be completed by February 09, 2026; however, there was no written documentation it was developed with the client until February 19, 2026.
Client #19 was admitted on March 27, 2025 and stepped down to the outpatient level of Care on May 13, 2025. A treatment and rehabilitation plan was due to be completed by March 03, 2025, however, there was no written documentation it was developed with the client until May 13, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During supervision on 3/25/2026, Program Manager has reeducated staff on the importance of timely treatment plans, treatment plan updates and documenting patient participation in developing the treatment plan. The Program Manager will perform random chart audits throughout the year to ensure compliance. |
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.
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Observations
Based on a review of partial hospitalization client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, in four of seven records reviewed.
Client #15 was admitted on May 17, 2025 and stepped down to the outpatient level of care on June 16, 2025. The record contained a progress note for an individual session occurring on December 20, 2023, that was not completed until January 7, 2024. Additionally, the record contained a progress note for a group session occurring on December 15, 2023, that was not completed until January 15, 2024.
Client #16 was admitted on January 15, 2026, and was active at the time of the inspection. The record contained a progress note for an individual session occurring on January 23, 2025, that was not completed until January 28, 2025.
Client #19 was admitted on March 27, 2025 and stepped down to the outpatient level of care on May 13, 2025. The record contained a progress note for individual sessions occurring on April 14, 2025, and April 18, 2025, that was not completed until April 17, 2025 and May 08, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on April 09, 2025, and April 10, 2025, that were not completed until April 25, 2025 and April 21, 2025, respectively.
Client #21 was admitted on December 02, 2025 and stepped down to the outpatient level of care on January 08, 2026. The record contained progress notes for an individual session occurring on December 02, 2025, that was not completed until January 02, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During supervision on 3/25/2026, team members were re-educated on the proper documentation protocols. The Program Manager has added this to the audit checklist and will monitor during monthly chart audit completion. Program Manager will address issues of noncompliance during individual supervision. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of outpatient 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 follow up information, per the facility's policy to be completed within 30 days of discharge in three out of four applicable records reviewed.
Client #23 was admitted on May 13, 2025, and discharged on June 09, 2025. The follow up was due to be completed by July 09, 2025; however, there was no documentation of a follow up being completed at the time of the inspection.
Client #27 was admitted on May 08, 2025, and discharged on August 06, 2025. The follow up was due to be completed by September 06, 2025; however, there was no documentation of a follow up being completed at the time of the inspection.
Client #28 was admitted on June 19, 2025, and discharged on September 25, 2025. The follow up was due to be completed by October 25, 2025; however, there was no documentation of a follow up being completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During supervision on 3/25/2026, team members were re-educated on the proper documentation protocols. The Program Manager and Office Manager will work in tandem to perform follow up calls on a weekly basis. Program Manager will review weekly with Office Manager to ensure follow up calls are completed in a timely manner. |