INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2022 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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709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness at the same time as the client on release of information forms in four of fourteen client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on December 7, 2021 and was discharged on January 7, 2022. The release of information form to the funding source was signed by the witness on November 26, 2021; however, the form was not signed by the client until November 30, 2021.
Client # 6 was admitted to the partial hospitalization activity on January 28, 2022 and discharged on February 11, 2022. The release of information form to the funding source was signed by the witness on January 26, 2022; however, the form was not signed by the client until January 27, 2022.
Client # 9 was admitted to the outpatient activity on February 14, 2022 and was still active at the time of the inspection. The release of information form to the funding source was signed by the witness on January 26, 2022; however, the form was not signed by the client until January 27, 2022.
Client # 14 was admitted to the outpatient activity on September 21, 2021 and was discharged on December 17, 2021. The release of information form to the funding source was signed by the witness on September 16, 2021; however, the form was not signed by the client until September 20, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will discuss and retrain staff on proper consent completion and the importance having the witness sign at the same time as the patient. Program Manager will completed monthly audit of random chart selection to ensure compliance. Clients 3 & 14 have been discahrged. Clients 6 & 9 have been corrected. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in two of six applicable client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on December 7, 2021 and was discharged on January 7, 2022. The client record did not document follow-up information as of the date of the inspection.
Client # 7 was admitted to the partial hospitalization activity on December 27, 2021 and was discharged on January 13, 2021. The client record did not document follow-up information 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
Program Manager will retrain staff during the next supervision session on the importance of proper follow up. Program Manager will perform monthly audits of random chart selection to ensure proper compliance. |
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 maintain a complete client record, which is to include follow-up information, in two of four applicable client records reviewed.
Client # 13 was admitted to the outpatient activity on November 18, 2021 and was discharged on January 24, 2022. The client record did not document follow-up information as of the date of the inspection.
Client # 14 was admitted to the outpatient activity on September 21, 2021 and was discharged on December 17, 2021. The client record did not document follow-up information 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
Program Manager will retrain staff during the next supervision session on the importance of proper follow up. Program Manager will perform monthly audits of random chart selection to ensure proper compliance. |