INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Livengrin Counseling Center, 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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709.28(c)(6) 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 shall be in writing and include, but not be limited to:
(6) Expiration date of the consent.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the date, event, or condition upon which the consent would expire in three of ten client records.
The findings include:
Ten client records requiring documentation of informed and voluntary consents were reviewed on February 6, 2015. The facility failed to document an informed and voluntary consent that included a date, event, or condition upon which the consent would expire in client records # 1, 3, and 4.
Client # 1 was admitted on July 28, 2014 and was still an active client at the time of the inspection. A consent for the Northampton County Adult Probation that was signed by the client on January 17, 2014 did not include a date, event, or condition upon which the consent would expire.
Client # 3 was admitted on April 28, 2014 and was still an active client at the time of the inspection. A consent for the Primary Care Physician and an attorney that were both signed by the client on April 28, 2014 did not include a date, event, or condition upon which the consent would expire. In addition a consent for Ms. Cooper signed by the client on September 24, 2014 did not include a date, event, or condition upon which the consent would expire.
Client # 4 was admitted on May 28, 2014 and discharged on July 30, 2014. A consent for the NCAP that was signed by the client did not include a date, event, or condition upon which the consent would expire.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
All releases will be updated to require including a date, event or condition upon which the consent would expire in order to save by 04/03/2015. This will be monitored by the Quality Assurance Manager. |
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 a review of client records, the facility failed to document a treatment plan update in five of seven client records.
The findings include:
Seven client records which required treatment plan updates were reviewed on February 6, 2015. The facility failed to document a treatment plan updates in client records #1, 2, 3, 8 and 10.
Client #1 was admitted on July 28, 2014 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on July 10, 2014. A treatment plan update was completed on September 11, 2014. A treatment plan update was due by November 11, 2014. The facility failed to document the completion of that treatment plan update as of February 6, 2015.
Client #2 was admitted on April 2, 2014 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on April 12, 2014. A treatment plan update was completed on April 29, 2014, July 25, 2014, August 19, 2014, and September 30, 2014. A treatment plan update was due by November 30, 2014. The facility failed to document the completion of that treatment plan update as of February 6, 2015.
Client #3 was admitted on April 28, 2014 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on April 29, 2014. The facility failed to document treatment plan updates as of February 6, 2015.
Client #8 was admitted on September 4, 2014 and discharged on December 18, 2014. The comprehensive treatment plan was completed on September 4, 2014. A treatment plan update was due by November 4, 2014. The facility failed to document the completion of that treatment plan update as of February 6, 2015.
Client #10 was admitted on June 30, 2014 and discharged on November 18, 2014. The facility failed to complete a comprehensive treatment plan as well as a treatment plan update as of February 6, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A revision to our internal auditing procedure is set to roll out by 09/01/2015. With this update, Sigmund, Livengrin's EMR system, will conduct automated audits rather than manual audits conducted by a staff member. This will ensure accuracy and promote a culture of compliance. Timely treatment plan updates will be a quality measure implemented within the new system. In the interim, clinical supervisors and members of the Quality Improvement team randomly audit charts on a weekly basis for the presence of all required documentation. Additionally, every active chart is audited weekly by a Quality Improvement team member to ensure that all documentation is complete. The current and projected audit systems are being overseen by the Quality Assurance Manager. |
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 provide a complete client record on each individual which included information relative to the client's involvement with the project in four of ten client records.
The findings include:
Ten client records were reviewed on February 6, 2015. The facility failed to provide a complete client record for clients #4, 5, 8, and 10.
Client #4 was admitted on May 28, 2014 and was discharged on July 30, 2014. The facility failed to document the completion of an aftercare plan and a discharge summary.
Client #5 was admitted on February 12, 2014 and discharged on July 8, 2014. The facility failed to document the completion of a case consultation.
Client #8 was admitted on September 4, 2014 and discharged on December 18, 2014. The facility failed to document the completion of a follow-up.
Client #10 was admitted on June 30, 2014 and discharged on November 18, 2014. The facility failed to document the completion of a case consult, aftercare plan, and a follow-up.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A revision to our internal auditing procedure is set to roll out by 09/01/2015. With this update, Sigmund, Livengrin's EMR system, will conduct automated audits rather than manual audits conducted by a staff member. This will ensure accuracy and promote a culture of compliance. Presence of case consultations, aftercare plans and follow up calls will be quality measures within the new audit system.In the interim, clinical supervisors and members of the Quality Improvement team randomly audit charts on a weekly basis for the presence of all required documentation. Additionally, every active chart is audited weekly by a Quality Improvement team member to ensure that all documentation is complete. The current and projected audit systems are being overseen by the Quality Assurance Manager. |