INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 2, 2011 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 and a plan of correction is due on April 4, 2011.
|
Plan of Correction
|
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on a review of the facility's policy and procedure manual and an interview with the quality assurance manager, the facility failed to develop a written policy and procedure by the project director that complies with 4 Pa. Code subsection 255.5 (a) (1).
The facility's policy titled: "Confidentiality", states:
"As of 4/1/03, HIPPA regulations require that requests for revocation of consents must be in writing." This policy is erroneous and it does not give the client the right to verbally revoke consent to release information. Also, in this policy, the facility is relying on a consent that has been revoked under 42 C.F.R. part 2 subpart C subsection 31 (c) (3).
An interview with quality assurance manger on February 8, 2011confirmed that the facility's policy and procedure on confidentiality does not comply with 4 Pa. Code subsection 255.5 (a) (1).
|
Plan of Correction
The Director, Total Quality Management will revise the Confidentiality Policy. The new policy will state that the patient has the right to revoke consents verbally or in writing. The Clinical Director will ensure that the policy is revised by 3/31/11. The revised policy will be distributed to all staff. All staff will need to complete a sign-off sheet, indicating that they have read and understood the revised policy. The Program Manager will randomly monitor patient charts, on a monthly basis, to ensure that releases are in compliance with the revised policy. Oversight will be provided by the Clinical Director. |
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:
|
Observations
Based on a review of client records and the facility's policy and procedure on client confidentiality, the facility failed to ensure that the client is notified of his/her right to revoke client consents to release information verbally or in writing in four of four records reviewed.
The findings include:
On March 2, 2011, four records were reviewed for consent to release information. The consent to release form had verbiage that only gave the client the right to revoke in writing in client records # 1, 2, 3, and 4. "I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it by notifying the Director of Medical Records or the Outpatient Program Manager in writing."
Also, from February 7, 2011 through February 11, 2011, the facility ' s policy and procedure on client confidentiality was reviewed. The facility policy on client confidentiality revised on February 1, 2006 stated that "As of 4/1/03, HIPPA regulations require that request for revocation of consents must be in writing". An interview with the quality assurance manager confirmed that the facility follows the HIPPA regulations and that all consent to release information forms include the statement that revocations of consent must be in writing.
Client record #1 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release for employee assistance program dated 10/4/10
2. Consent to release to family member dated 10/04/10
3. Consent to release to medical practitioner dated 10/04/10.
4. Consent to release to an insurance company dated 10/04/10
5. Consent to release to a managed care organization dated 10/4/10
Client record #2 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release to family member dated 10/19/10
2. Consent to release to a medical practitioner dated 10/19/10
3. Consent to release to a government agency dated 11/16/10
4. Consent to release to an insurance company dated 10/19/10
Client record #3 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release to family member dated 1/24/11
2. Consent to release to a medical practitioner dated 1/24/11
3. Consent to release to an insurance company dated 1/24/11
4. Consent to release to family to a managed care organization dated 1/24/11
Client record #4 contained the following consents to release information that did not allow for the verbal revocation of the consents:
1. Consent to release to the employer for employee assistance program dated 2/1/11
2. Consent to release to an insurance company dated 1/25/11
An interview with the program manager on March 2, 2011 confirmed that client records # 1, 2, 3, and 4 contained consent to release informations that did not allow for the verbal revocation of the consent.
|
Plan of Correction
The Director, Total Quality Management will revise all relavent consents, by 3/25/11. Revised consents will state that the patient has the right to revoke consents verbally or in writing. The Clinical Director will ensure that the revisions occur by 3/25/11. The revised consents will be sent to the Information Technology Department by 3/25/11. They will remove the incorrect consents and add the revised consents to the electronic record, by 3/28/11. The Director, Total Quality Management will inform the Program Manager, by 3/28/11, that the revised consents are in the electronic record. The Program Manager will inform counselors, on 3/28/11, that revisions have been made to the consents. All future patients, starting with 3/28/11, will be required to read and sign the revised consents. All current patients will be required to read and sign revised consents at the time of their next session, starting 3/28/11. the Program Manager will randomly monitor patient charts, on a monthly basis, to ensure that the revised consents are being used. Oversight will be provided by the Clinical Director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and an interview with the program manager, the facility failed to document a psychosocial evaluation that included an assessment of the client's problems/needs, assets/strengths that can contribute to the resolution of client's problems, support systems, coping mechanisms, negative factors that might affect client's treatment, attitude toward treatment, and/or counselor's conclusions/impressions in four of four client records reviewed.
Also, based on a review of client records and an interview with the program manager, the facility failed to document a psychosocial evaluation as per the facility's policy in one of four records reviewed.
The findings include:
On March 2, 2011, four client records were reviewed for psychosocial evaluations. The facility failed to document a psychosocial evaluation that included an assessment of the client's problems/needs, assets/strengths that can contribute to the resolution of client's problems, support systems, coping mechanisms, negative factors that might affect client's treatment, attitude toward treatment, and/or counselor's conclusions/impressions in client records # 1, 2, 3, and 4. Also, the facility failed to document a psychosocial evaluation according to their policy in client record # 3.
The facility's policy titled: "Psychosocial Evaluation " states:
"A Psychosocial Evaluation (Clinical Summary) will be completed by the primary counselor by the seventh day of treatment and a re-evaluation will be done within three days/sessions when the patient moves to another level of care.
The evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the patient's current situation.
The evaluation is not meant to be an extensive document nor a replication of information already documented in the initial assessment. Rather, it is meant to be a formulation of the following elements as a bridge to the master treatment plan/treatment plan update:
A clear description of the patient's presenting and underlying problems. A Patient needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
Patient assets, strengths or other factors that can contribute to the resolution of identified problems. The potential or available patient support systems. Negative factors that might affect treatment. The patient's preferred coping mechanisms. Conclusions regarding the patient's appearance, behavior and reactions during the intake process. Conclusions regarding the patient's attitude toward and ability to participate in the treatment process. "
Client # 1 was admitted October 4, 2010. The psychosocial evaluation was completed on October 11, 2010, but it did not include an evaluation of the client's assets/strengths, support systems, and negative factors.
Client # 2 was admitted October 19, 2010. The psychosocial evaluation was completed on October 27, 2010, but it did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and counselor's conclusions/impressions.
Client # 3 was admitted January 24, 2011; however, the facility did not document the psychosocial evaluation until February 24, 2011. Also, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, attitude toward treatment, and counselor's conclusions/impressions.
Client # 4 was admitted January 25, 2011. The psychosocial evaluation was completed on February 1, 2011, but it did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor ' s conclusions/impressions.
An interview with the program manager on March 2, 2011 confirmed that client records # 1, 2, 3, and 4 did not include an evaluation of the information identified in this report. Also, an interview with the program manager on the same day confirmed that that the facility did not document a psychosocial evaluation in accordance with their policy in client record # 3.
This is a repeat citation. The facility was cited on February 12, 2009 and on March 21, 2008 for psychosocial evaluations.
The facility's Plan of Correction for the February 12, 2009 citation was as follows:
"In a meeting on 3/25/09, the Clinical Supervisor will educate counselors of the need to complete a psychosocial evaluation for all patients that contains all required elements, including assets/strengths, support systems, coping mechanisms and negative factors. Compliance will be monitored by the Clinical Supervisor on a monthly basis. The Outpatient Director will be responsible for oversight."
The facility's Plan of Correction for the March 21, 2008 citation was as follows:
"In a meeting, the Program Director will remind counselors to include all required elements in the psychosocial evaluation. The Program Manager will follow up through the chart auditing process. Compliance will be monitored by the TQM Director".
|
Plan of Correction
The Director, Total Quality Management will ensure that Livengrin's Psychosocial Evaluation will be revised to include all required elements. The revision will occur by 3/25/11. In a meeting on 4/1/11, the Program Manager will inform all counselors of the revision, and of the need to include a Psychosocial Evaluation in all patient charts, by the seventh day of treatment. The Program Manager will randomly review patient charts to ensure compliance. The Program Manager will also ensure that a psychosocial evaluation, including all required elements will be documented in charts #1,#2,#3 and #4. Compliance for these charts will be monitored, in the electronic record, by the Director, Total Quality Management. Oversight will be provided by the Clinical Director. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
|
Observations
Based on a review of client records and an interview with the program manager, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan in four of four records reviewed.
The findings include:
On March 2, 2011, four client records were reviewed for documentation for short and long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan. The facility did not document the long-term goals for treatment in client records # 1, 2, 3, and 4.
The facility ' s policy titled: "Treatment Planning," states:
" On or before the seventh day of treatment (or by the third day of treatment for patients enrolled in the Dual Diagnosis Program), formulate the Master Treatment Plan utilizing the preliminary treatment plan an input from all disciplines and the patient, identifying how the patient is involved in the treatment planning process.
Long-term goals, short-term goals and action steps should be realistic, reflect behaviorally defined problem statements, and stated in terms of measurable and behaviorally based criteria. Identify type and frequency and methods of treatment/modality along with any support services recommended and including who is responsible for the implementation of the interventions (e.g., medical, legal, etc). Reflect interventions and action steps utilized along with identification of persons responsible for the implementation of interventions. Identify a planned target date for completion of the action steps. Reflect initial discharge planning. "
Client # 1 was admitted on October 4, 2010. The treatment plan was completed on October 18, 2010 but did not include documentation for the long-term goals for treatment.
Client # 2 was admitted on October 19, 2010. The treatment plan was completed on November 3, 2010 but did not include documentation for the long-term goals for treatment.
Client # 3 was admitted on January 24, 2011. The treatment plan was completed on February 10, 2011 but did not include documentation for the long-term goals for treatment.
Client # 4 was admitted on January 25, 2011. The treatment plan was completed on February 28, 2011 but did not include documentation for the long-term goals for treatment.
An interview with the program manager on March 2, 2011 confirmed that the treatment plans in client records # 1, 2, 3, and 4 did not include documentation for the long-term goals for treatment.
|
Plan of Correction
In a meeting, on 4/1/11, the Program Manager will remind counselors of the need for the Treatment Plan to include long-term goals, as formulated by both staff and patient. The Program Manager will randomly review patient charts to ensure compliance. Oversight will be provide by the Clinical Director. |
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.
|
Observations
Based on a review of client records and an interview with the program manager, the facility failed to indicate the client ' s progress in the treatment and rehabilitation plan update in two of two records reviewed.
Also, based on a review of client records and an interview with the program manager, the facility failed to document a treatment and rehabilitation plan update as per facility ' s policy in two of two records reviewed.
The findings include:
On March 2, 2011, two client records were reviewed for treatment plan updates. The facility failed to document a treatment and rehabilitation plan update that included an indication of the client ' s progress in client records # 1 and 2. Also, the facility did not document a treatment and rehabilitation plan update according to their policy on treatment planning in client records # 1 and 2.
The facility ' s policy titled: "Treatment Planning, " states:
"For Intensive Outpatient and General Outpatient treatment, the Counselor will review and update the treatment plan at least every sixty (60) days from the date of the Master Treatment Plan/Update. The treatment plan update should include an assessment of the patient ' s progress in relationship to the stated goals of the master treatment plan. "
Client # 1 was admitted October 4, 2010; however, the facility did not document the treatment and rehabilitation plan update until January 11, 2011. Also, the treatment and rehabilitation plan update did not include an indication of the client ' s progress.
Client # 2 was admitted October 19, 2010; however, the facility did not document the initial treatment and rehabilitation plan update until February 28, 2011. Also, the treatment and rehabilitation plan update did not include an indication of the client ' s progress.
An interview with the program manager on March 2, 2011 confirmed that client records # 1 and 2 treatment and rehabilitation plan update did not include an indication of the client ' s progress. Also, an interview with the program manager on the same day confirmed that the facility did not document a treatment and rehabilitation plan update in accordance with their policy in client records # 1 and 2.
|
Plan of Correction
In a meeting. on 4/1/11, the Program Manager will remind counselors that Treatment Plan Updates are to be completed at least every sixty days, and the need to include an indication of the patient's progress. The Program Manager will randomly monitor patient charts for compliance. Oversight will be provided by the Clinical Director. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
|
Observations
Based on a review of personnel records and an interview with the quality assurance manager, the facility failed to document an assessment of staff training needs in five of five personnel records reviewed.
The findings include:
From February 7, 2011 through February 9, 2011, five personnel records were reviewed for documentation of an assessment of staff training needs. The facility failed to document an assessment of staff training needs in personnel records # 1, 2, 3, 4, and 5.
An interview with the quality assurance manager conducted on February 9, 2011 confirmed that the facility did not document an assessment of staff training needs in the personnel records # 1, 2, 3, 4, and 5.
|
Plan of Correction
The Director, Total Quality Management will revise the Staff Growth and Development Program to inlude an assessment of staff training needs, by 3/31/11, to include an assessment of staff training needs assessment form for each training year. The Program Manager will be responsible to ensure that she receives this form from all staff. The Director, Total Quality Management, will review compliance for all staff, on a yearly basis, and inform the Manager about staff who are missing the staff training needs assessment form. For missing forms, the Director, Total Quality Management will will review compliance on a weekly basis, until all forms have been received. Oversight will be provided by the Clinical Director. |
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.
|
Observations
Based on review of personnel records, staffing requirements facility summary report, and interview with the quality assurance manager, the facility failed to ensure that the project director and facility director completed 12 clock hours of required training in one of two personnel records reviewed.
The findings include:
From February 7, 2011 through February 9, 2011, two personnel records were reviewed for documentation of the required 12 hours of training. The facility failed to document 12 clock hours of training in personnel record # 1.
Employee # 1, the project director, was hired October 26, 1987. The facility's training year is from July through June. The training year for July 1, 2009 to June 3, 2010 was reviewed. Personnel record # 1 only had documentation of 9 clock hours of training for the July 1, 2009 to June 3, 2010 training year.
An interview with the quality assurance manager on February 9, 2011 confirmed that personnel record # 1 only had documentation of 9 clock hours of training for the July 1, 2009 to June 3, 2010 training year.
|
Plan of Correction
The Director, Total Quality Management will remind the Project Director of the need to obtain 12 training hours 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 Manager, on a monthly basis, until the requirement has been met. |