INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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) 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.
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Observations
Based on the review of 7 client records, the facility failed to ensure that there was a consent to release information form completed with the client prior to the disclosure of information in 1 record reviewed.
Client #3 was admitted on 3/09/2017 and was still active at the time of the inspection. There was documentation that on 12/18/17, medical records were faxed to a government agency; however, there was no release of information form signed by the client prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The importance of confidentiality and proper releases was discussed with Medical Records Staff on April 4th, 2018 by Director of Quality Improvement. The Director of Quality Improvement will regularly monitor the input and execution of proper releases. |
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 7 client records, the facility failed to document that client orientation had taken place in 3 records reviewed.
Client #4 was admitted on 5/09/2017 and was discharged on 8/28/2017.
Client #6 was admitted on 6/27/2017 and was discharged on 2/24/2018.
Client #7 was admitted on 3/06/2017 and was discharged on 10/02/2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 May 17th, 2018, which will highlight orientation requirements. The Director of Quality Improvement will be responsible for the ongoing monitoring of orientation documentation compliance. |
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 7 client records, the facility failed to document treatment plan updates within the regulatory timeframe in 3 client records.
Client #3 was admitted on 3/09/2017 and was still active at the time of the inspection. A treatment plan update was completed on 10/27/17 and the next update was due no later than 12/28/17; however, the update was not documented until 1/23/18.
Client #6 was admitted on 6/27/2017 and was discharged on 2/24/2018. The comprehensive treatment plan was completed on 7/03/17 and the next update was due no later than 9/03/17; however, the update was not documented until 10/16/17.
Client #7 was admitted on 3/06/2017 and was discharged on 10/02/2017. A treatment plan update was completed on 4/25/17 and the next update was due no later than 6/25/17; however, the update was not documented until 8/01/17. Additionally, the next update was due no later than 10/01/17, however, there was no update completed prior to client ' s discharge from treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 May 17th, 2018, which will focus on treatment planning. The Director of Quality Improvement will be responsible for the ongoing monitoring of treatment plan compliance. |