INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2016 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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709.30 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 a review of client records, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in two of eight client records reviewed.
The findings include:
Eight client records requiring the written, signed confirmation by the client of their client rights were reviewed on January 28, 2016. The facility did not provide such documentation in client record, #'s 1 and 4.
Client # 1 was admitted into treatment on April 23, 2015 and was discharged on June 10, 2015. The facility failed to include documentation of the client rights in the client record as of the date of the inspection.
Client # 4 was admitted into treatment on September 30, 2014 and was discharged on February 23, 2015. The facility failed to include documentation of the client rights in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 seven of eight client records.
The findings include:
Eight client records requiring documentation of client orientation were reviewed on January 28, 2016. The facility did not provide such documentation in client records #1, 2, 3, 4, 5, 6, and 8.
Client #1 was admitted into treatment on April 23, 2015 and was discharged on June 10, 2015. There was no documentation of client orientation in the client record as of the date of the inspection.
Client #2 was admitted into treatment on July 30, 2015 and was discharged on December 10, 2015. There was no documentation of client orientation in the client record as of the date of the inspection.
Client #3 was admitted into treatment on February 10, 2015 and was discharged on November 3, 2015. There was no documentation of client orientation in the client record as of the date of the inspection.
Client #4 was admitted into treatment on September 30, 2014 and was discharged on February 23, 2015. There was no documentation of client orientation in the client record as of the date of the inspection.
Client #5 was admitted into treatment on September 21, 2015 and was discharged on November 6, 2015. There was no documentation of client orientation in the client record as of the date of the inspection.
Client #6 was admitted into treatment on December 15, 2015 and was still an active client as of the date of the inspection. There was no documentation of client orientation in the client record as of the date of the inspection.
Client #8 was admitted into treatment on October 26, 2015 and was still an active client as of the date of the inspection. There was no documentation of client orientation in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Orientations were completed and documented wherever possible (in the charts of active patients).The importance of documenting orientation as a part of the intake procedure 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 include orientation documentation as a key point. 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 provide documentation that the individual treatment and rehabilitation plan was developed with the client in four of eight client records reviewed. Additionally, the facility failed to document the frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of eight client records.
The findings include:
Eight client records requiring the documentation of the client-involved development of the individual treatment and rehabilitation plan were reviewed on January 28, 2016. All individual treatment and rehabilitation plans are also to include documentation of the frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans in client record #'s 3, 4, 5, and 8 did not include verification that the plan was developed with the client. Additionally, the treatment plans in client record #'s 1, 2, and 5 did not include the frequency of treatment and rehabilitation services.
Client #1 was admitted into treatment on April 23, 2015 and was discharged on June 10, 2015. The individual treatment and rehabilitation plan was developed on 05/22/2015, but did not include the frequency of treatment services.
Client #2 was admitted into treatment on July 30, 2015 and was discharged on December 10, 2015. The individual treatment and rehabilitation plan was developed on 07/30/2015, but did not include the frequency of treatment services.
Client #3 was admitted into treatment on February 10, 2015 and was discharged on November 3, 2015. The individual treatment and rehabilitation plan was developed by the counselor on 04/07/2015, but did not include the client signature indicating the plan was developed with input from the client.
Client #4 was admitted into treatment on September 30, 2014 and was discharged on February 23, 2015. The individual treatment and rehabilitation plan was developed by the counselor on 10/14/2014, but did not include the client signature indicating the plan was developed with input from the client.
Client #5 was admitted into treatment on September 21, 2015 and was discharged on November 6, 2015. The individual treatment and rehabilitation plan was developed by the counselor on 10/02/2015, but did not include the client signature indicating the plan was developed with input from the client. Additionally, the 10/02/2015 individual treatment plan did not include the frequency of treatment services.
Client #8 was admitted into treatment on October 26, 2015 and was still an active client at the time of the inspection. The individual treatment and rehabilitation plan was developed by the counselor on 12/31/2015, but did not include the client signature indicating the plan was developed with input from the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans were updated wherever possible (in the charts of active patients). The importance of timely and quality treatment plans was shared with the offending clinical staffs. 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. |