INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16, 2012 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.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel records.
The findings include:
Six personnel records were reviewed on March 7-8, 2012. One personnel record pertained to the project director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the facility director since October 26, 1987. The facility training year is from July 1, 2010 through June 30, 2011. Employee # 1 had documentation of 5 training hours listed for the 2010-2009 training year.
A discussion with the Quality Improvement Director on March 8, 2012 confirmed the findings.
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Plan of Correction
The Director, Total Quality Management, will remind the Project Director of the need to obtain twelve credits for each training year. The Director, Total Quality Management will monitor compliance on a monthly basis. If compliance has not been met, the Director, Total Quality Management will review the requirement with the Project Director, on a monthly basis, until the requirement has been met. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all exits were unobstructed.
The findings included:
A physical plant inspection took place on March 20, 2012. The second exit located in a counselor's office was locked and a key had to be used to unlock the counselor's office. An interview with facility staff on March 20, 2012 confirmed the findings.
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Plan of Correction
The Program Manager will ensure, through daily inspections, that all exits are unobstructed. The Program Manager will develop a checklist where she will indicate her daily check to ensure that all exits are unobstructed. The Program Manager will submit the checklist to the Director, Total Quality Management on a weekly basis. |
709.24(c) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(c) The project shall maintain a current community resource listing of other health and social service agencies.
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Observations
Based on a review of policy and procedures, the facility failed to have a community resource book listing other health and social service agencies.
The findings include:
The policy and procedures were reviewed on March 20, 2012. The facility failed to produce a copy of the community resource book that provided other health and social service agencies. An interview with facility staff on March 20, 2012 confirmed the findings.
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Plan of Correction
The Program Manager will develop a community resource book listing other health and social service agencies. The Program Manager will update the community resource book on a quarterly basis. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that the client was notified of his/her right to revoke client consents to release information verbally or in writing in six of six client records.
The findings include:
Six client records were reviewed on March 16, 2012. Six client records were required to have informed and voluntary consent forms that documented on the form that the client was notified of his/her right to revoke a consent to release information verbally or in writing. The right to revoke the consent verbally or in writing was not documented on the informed and voluntary consent forms for insurance companies in client records, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Director, Total Quality Management, will revise all relavent consents by 4/30/12. Revised consents will state that the patient has the right to revoke consents verbally or in writing. The revised consents will be sent to the Information Technology Department by 4/30/12. The Department will remove the incorrect consents and add the revised consents to the electronic record by 4/30/12. The Director, Total Quality Management will inform the Program Manager, by 4/30/12, that the revised consents are contained in the electronic record. The Program Manager will inform all Counselors by email that revisions have been made to consents. All future and current patients, as of 4/30/12, will be required to read and sign the revised consents. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in six of six partial hospitalization activity client records.
The findings include:
Six client records were reviewed on March 16, 2012. Six client records reviewed were required to have documentation of psychosocial evaluations, #1, 2, 3, 4, 5 and 6. An interview with facility staff on March 20, 2012 confirmed the findings.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors and how they would impact treatment.
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Plan of Correction
In a meeting, on 3/26/12, the Program Manager reminded all counselors of the need to document a psychosocial evaluation within seven days of the patient's admission, and that all required elements need to be included. The Program Manager will randomly monitor patient charts on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
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 treatment plans within the facility's in five of six client records.
The finding includes:
Six client records were reviewed on March 16, 2012. Treatment plans were reviewed in six client records, #1, 2, 3, 4, 5 and 6. Per the facility's policy, treatment plans will be completed within 7 days of the client's admission date following the completion of the client's biopsychosocial history and evaluation. A discussion with facility staff on March 20, 2012 confirmed the findings.
Client #1 was admitted on February 14, 2012 and the treatment plan was completed on March 11, 2012. The therapist signed the treatment plan on March 11, 2012 and the client did not sign the treatment plan as of March 16, 2012. It could not be determined if the treatment plan was developed with the client.
Client #2 was admitted on January 26, 2012 and the treatment plan was completed on February 27, 2012. Client record #2's treatment plan was completed on February 27, 2012 before the completion of the client's psychosocial evaluation which was not documented. Also, the therapist signed the treatment plan on February 13, 2012 and the client did not sign the treatment plan until March 27, 2012. It could not be determined if the treatment plan was developed with the client.
Client #3 was admitted on January 17, 2012 the treatment plan was completed on February 16, 2012. The therapist signed the treatment plan on February 16, 2012 and the client did not sign the treatment plan as of March 16, 2012. It could not be determined if the treatment plan was developed with the client.
Client #4 was admitted on January 17, 2012 and discharged on February 28, 2012. The treatment plan was completed on January 26, 2012. The therapist signed the treatment plan on January 26, 2012 and the client signed the treatment on February 23, 2012. It could not be determined if the treatment plan was developed with the client.
Client #6 was admitted on November 28, 2012 and discharged on January 5, 2012. The treatment plan was completed on December 14, 2011. The therapist signed the treatment plan on December 14, 2011 and the client signed the treatment on January 18, 2012. It could not be determined if the treatment plan was developed with the client.
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Plan of Correction
In a meeting, on 3/26/12, the Program Manager reminded all Counselors of the need to complete treatment plans within seven days of admission, after completion of the psychosocial evaluation, and that treatment plans need to be developed with the patient. The Program Manager will randomly monitor patient charts on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of three discharge records.
The findings include:
Six client records were reviewed on March 16, 2012. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completions. An aftercare plan was required in two client records. The facility did not document an aftercare plan in client record #6.
Client # 6 was admitted on November 28, 2011 and discharged on January 5, 2012. There was no documentation of an aftercare plan in client record #6.
This was discussed and confirmed with the facility director on March 20, 2012.
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Plan of Correction
In a meeting, on 3/26/12, the Program Manager reminded all counselors of the need to complete an aftercare plan with all patients, when appropriate. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
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.
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Observations
Based on a review of client records, the facility failed to document discharge summaries in one of three discharge records reviewed.
The findings include:
Six client records were reviewed on March 16, 2012. Per the facility's policy, discharge summaries are required within 7 days of a client's discharge date and also must include the reason for treatment, support services, response to treatment and client status at discharge. Discharge summaries were not documented in client record, #4.
Client #4 was admitted on January 17, 2012 and discharged on February 28, 2012. The discharge summary was to be completed by March 6, 2012. As of the date of the inspection the discharge summary was not documented in client record #4.
An interview with facility staff on March 20, 2012 confirmed the findings.
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Plan of Correction
In a meeting, on 3/26/12, the Program Manager reminded all Counselors of the need to document a discharge summary for all patients. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. Oversight will be provided by the Director, Total Quality Management. The discharge summary for patient #4 will be completed by 5/9/12, and will be reviewed by the Program Manager to ensure completion. |
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 client records, the facility failed to document follow-up information in one of three discharge client records.
The findings include:
Six client records were reviewed on March 16, 2012. Per the facility policy, the counselor will complete the follow-up documentation with 7 days for referrals, 7 days for unsuccessful discharges and 30 days for successful completions. Follow-up documentation was required in two discharge client records, #5 and 6. The facility did not document a discharge summary in client record #5.
Client #5 was admitted December 27, 2011 and was discharged on January 12, 2012. The follow-up was to be done by January 18, 2012. There was no documentation of a follow-up in client record #5.
An interview with facility staff on March 20, 2012 confirmed the findings.
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Plan of Correction
In a meeting, on 3/26/12, the Program Manager reminded all counselors of the need to document follow-up information for all patients. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure compliance. The Quality Management Assistant will also monitor patient charts randomly, on a monthly basis. Consequences will be imposed on staff who continue to have the same deficiency. Oversight will be provided by the Director, Total Quality Management. Follow-up will be completed for patient #5 by 5/9/12, and will be reviewed by the Program Manager to ensure completion. |