INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 2, 2011 licensure renewal inspection. The follow-up inspection was conducted on October 3, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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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 review of personnel records, the facility failed to ensure that the project director completed 12 clock hours of required training.
The findings include:
On September 13, 2011, one personnel record requiring documentation of 12 clock hours of training for the project director was reviewed at the project's main location. The facility did not document 12 clock hours of training in one of one record reviewed, specifically, personnel record # 1.
Employee # 1, the project director, was hired on October 26, 1987. The facility's training year is from July 1, 2010 to June 30, 2011. Employee # 1's personnel record only had documentation of 5 clock hours of training for the July 1, 2010 to June 30, 2011 training year as of September 13, 2011.
During an ongoing dialogue with the quality assurance manger conducted on September 13, 2011 from approximately 1:00 P.M. to 1:30 P.M., the findings were confirmed.
This is a repeat citation. The facility was cited on March 2, 2011 on annual training requirements for the project director.
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Plan of Correction
The Director, Total Quality Management will remind the Project Director of the need to obtain twelve training hours for each training year. The Director, Total Quality Management will monitor compliance on a monthly basis. If the requirement has not been met, the Director, Total Quality Management will review the requirement with the Project Director on a monthly basis, until the requirement is met. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation upon arriving at the facility on October 3, 2011, the facility failed to ensure that heaters that are not permanently mounted or installed were not permitted in the facility.
The findings include:
Upon arriving at the facility, it was observed at approximately 9:59 A.M. that there was a portable space heater located in one of the counselor's office.
During an interview with the facility director conducted on October 3, 2011 at approximately 11:30 A.M., the findings were confirmed.
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Plan of Correction
On 9/30/11, the heater was removed from the counselor's office. In a meeting on 10/3/11, the Program Manager reminded all staff that heaters are not permitted in staff offices or other areas of the Allentown Site. compliance will be monitored on a daily basis, by the Program Manager. 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.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation.
Also, based on a review of client records, the facility failed to document a psychosocial evaluation in accordance with their policy and procedures.
The findings include:
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."
On October 3, 2011, seven client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation in four of seven records reviewed, specifically, client records # 1, 2, 3, and 4. Also, the facility did not document a psychosocial evaluation according to their policy and procedures in three of seven records reviewed, specifically, client records # 5, 6, and 7.
Client # 1 was admitted August 29, 2011. The psychosocial evaluation for client # 1 was due September 5, 2011; however, client record # 1 did not include documentation of a psychosocial evaluation as of October 3, 2011.
Client # 2 was admitted July 25, 2011. The psychosocial evaluation for client # 2 was due August 1, 2011; however, client record # 2 did not include documentation of a psychosocial evaluation as of October 3, 2011.
Client # 3 was admitted September 1, 2011. The psychosocial evaluation for client # 3 was due September 8, 2011; however, client record # 3 did not include documentation of a psychosocial evaluation as of October 3, 2011.
Client # 4 was admitted June 6, 2011. The psychosocial evaluation for client # 4 was due June 13, 2011; however, client record # 4 did not include documentation of a psychosocial evaluation as of October 3, 2011.
Client # 5 was admitted April 11, 2011. The psychosocial evaluation was completed on April 14, 2011, but it did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 6 was admitted May 10, 2011. The psychosocial evaluation was completed on May 13, 2011, but it did not include an evaluation of the client's assets/strengths, coping mechanisms, and attitude toward treatment.
Client # 7 was admitted April 4, 2011. The psychosocial evaluation was completed on April 11, 2011, but it did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
During an ongoing dialogue with the facility director conducted on October 3, 2011 from approximately 2:00 P.M. to 3:00 P.M., the findings were confirmed.
This is a repeat citation. The facility was cited on March 2, 2011; February 12, 2009; and March 21, 2008 for noncompliance with this standard.
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Plan of Correction
In a meeting, on 11/3/11, the Program Manager will remind all counselors of the need to complete a psychosocial evaluation on all patients by the seventh day of treatment, and also of the need to include all required elements. The Program Manager will randomly monitor patient charts to ensure that all psychosocial evaluations are documented in accordance with Livengrin's policy and procedures. The Quality Assurance Assistant will randomly monitot patient charts to ensure that all psychosocial evaluations are documented in accordance with Livengrin's policy and procedures. Psychosocial evaluations will be completed for patients 1,2,3,and4. Oversight will be provided by the Clinical Director. |
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 an individual treatment and rehabilitation upon the completion of the psychosocial evaluation.
Also, based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan in accordance with their policy an procedures.
The findings include:
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."
On October 3, 2011, seven records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility did not document an individual treatment and rehabilitation plan according to their policy and procedures in seven of seven records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, and 7. Also, the facility did not document an individual treatment and rehabilitation plan upon the completion of the psychosocial evaluation in four of seven records reviewed, specifically, client records # 1, 2, 3, and 4.
Client # 1 was admitted August 29, 2011. The individual treatment and rehabilitation plan was due September 5, 2011 but the individual treatment and rehabilitation plan was not completed until September 19, 2011. Also, client record # 1 did not include documentation of a psychosocial evaluation as of October 3, 2011.
Client # 2 was admitted July 25, 2011. The individual treatment and rehabilitation plan was due August 1, 2011 but the individual treatment and rehabilitation plan was not completed until August 4, 2011. Also, client record # 2 did not include documentation of a psychosocial evaluation as of October 3, 2011.
Client # 3 was admitted September 1, 2011. The individual treatment and rehabilitation plan was due September 8, 2011 but the individual treatment and rehabilitation plan was not completed until September 21, 2011. Also, client record # 3 did not include documentation of a psychosocial evaluation as of October 3, 2011.
Client # 4 was admitted June 6, 2011. The individual treatment and rehabilitation plan was due June 13, 2011 but the individual treatment and rehabilitation plan was not completed until June 29, 2011. Also, client record # 4 did not include documentation of a psychosocial evaluation as of October 3, 2011.
Client # 5 was admitted April 11, 2011. The individual treatment and rehabilitation plan was due April 18, 2011 but the individual treatment and rehabilitation plan was not completed until May 26, 2011.
Client # 6 was admitted May 10, 2011. The individual treatment and rehabilitation plan was due May 17, 2011 but the individual treatment and rehabilitation plan was not completed until May 23, 2011.
Client # 7 was admitted April 4, 2011. The individual treatment and rehabilitation plan was due April 11, 2011 but the individual treatment and rehabilitation plan was not completed until May 1, 2011.
During an ongoing dialogue with the facility director conducted on October 3, 2011 from approximately 2:00 P.M. to 3:00 P.M., the findings were confirmed.
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Plan of Correction
In a meeting, on 10/2/11, the Program Manager reminded all counselors of the need to complete Individual Treatment Plans for all patients by the seventh day of treatment, also that the Psychosocial Evaluations needs to be completed prior to the completion of the Individual Treatment Plan. The Program Manager will randomly monitor patient charts to ensure that all individual treatment plans are documented in accordance with Livengrin's policy and procedures, and that psychosocial evaluations are completed prior to the completion of individual treatment plans The Quality Assurance Assistant will randomly monitor patient charts to ensure that all Individual Treatment Plans are documented in accordance with Livengrin's policy and procedures, and that psychosocial evaluations are completed prior to the completion of Individual Treatment Plans. Oversight will be provided by the Clinical Director. 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.
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Observations
Based on a review of client records, 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.
The findings include:
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."
On October 3, 2011, seven client records requiring documentation of short and long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in five of seven records reviewed, specifically, client records # 3, 4, 5, 6, and 7.
Client # 3 was admitted September 1, 2011. The individual treatment and rehabilitation plan was completed on September 21, 2011 but it did not include documentation of the long-term goals for treatment as of October 3, 2011
Client # 4 was admitted June 6, 2011. The individual treatment and rehabilitation plan was completed on June 29, 2011 but it did not include documentation of the long-term goals for treatment as of October 3, 2011.
Client # 5 was admitted April 11, 2011. The individual treatment and rehabilitation plan was completed on May 26, 2011 but it did not include documentation of the long-term goals for treatment as of October 3, 2011.
Client # 6 was admitted May 10, 2011. The individual treatment and rehabilitation plan was completed on May 23, 2011 but it did not include documentation of the long-term goals for treatment as of October 3, 2011.
During an ongoing dialogue with the facility director conducted on October 3, 2011 from approximately 2:00 P.M. to 3:00 P.M., the findings were confirmed.
This is a repeat citation. The facility was cited on March 2, 2011 for noncompliance with this standard.
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Plan of Correction
In a meeting, on 10/3/11, the Program Manager reminded all counselors of the need to include long term goals in Individual Treatment Plans. The Program Manager will randomly monitor patient charts to ensure compliance. Oversight will be provided by the Clinical Director. Also, the Quality Assurance Assistant will randomly monitor patient charts to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
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 client records, the facility failed to document a treatment and rehabilitation plan update in accordance with their policy and procedures.
Also, based on a review of client records, the facility failed to document a treatment and rehabilitation plan update
The findings include:
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."
On October 3, 2011, five client records requiring documentation of a treatment and rehabilitation plan update were reviewed. The facility failed to document a treatment and rehabilitation plan update in accordance with their policy and procedures in two of five records reviewed, specifically, client records # 2 and 7. Also, the facility failed to document a treatment and rehabilitation plan update in three of five records reviewed, specifically, client records # 4, 5, and 6.
Client # 2 was admitted July 25, 2011 and the individual treatment and rehabilitation plan was completed on August 4, 2011. The treatment and rehabilitation plan update was completed on September 27, 2011; however, the treatment and rehabilitation plan update did not include an indication of the client's progress as of October 3, 2011.
Client # 4 was admitted June 6, 2011 and the individual treatment and rehabilitation plan was completed on June 29, 2011. The treatment and rehabilitation plan update was for client # 4 was due August 28, 2011; however, client record # 4 did not include documentation of a treatment and rehabilitation plan update as of October 3, 2011.
Client # 5 was admitted April 11, 2011 and the individual treatment and rehabilitation plan was completed on May 26, 2011. The treatment and rehabilitation plan update was for client # 5 was due July 25, 2011; however, client record # 5 did not include documentation of a treatment and rehabilitation plan update as of October 3, 2011.
Client # 6 was admitted May 10, 2011 and the individual treatment and rehabilitation plan was completed on May 23, 2011. The treatment and rehabilitation plan update was for client # 6 was due July 22, 2011; however, client record # 6 did not include documentation of a treatment and rehabilitation plan update as of October 3, 2011.
Client # 7 was admitted April 4, 2011 and the individual treatment and rehabilitation plan was completed on May 1, 2011. The treatment and rehabilitation plan update was completed on May 23, 2011; however, the treatment and rehabilitation plan update did not include an indication of the client's progress as of October 3, 2011.
During an ongoing dialogue with the facility director conducted on October 3, 2011 from approximately 2:00 P.M. to 3:00 P.M., the findings were confirmed.
This is a repeat citation. The facility was cited on March 2, 2011; March 21, 2008; and July 18, 2006 for noncompliance with this standard.
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Plan of Correction
In a meeting, on 10/3/11, the Program Manager reminded all counselors that Individual Treatment Plan Updates need to be completed at least every sixty days and that they need to include patient progress in treatment.
The Program Manager will randomly monitor patient charts to ensure that individual treatment plan updates are completed in accordance with Livengrin's policy and procedures. O The Quality Assurance Assistant will randomly monitor patient charts to ensure individual treatment plan updates are completed in accordance with Livengrin's policy and procedures. Individual treatment plan upddates will be completed on patients 4,5 and 6. Oversight will be provided by the Clinical Director. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation in accordance with their policy and procedures.
Also, based on a review of client records, the facility failed to document a case consultation that included documentation of a summary and disposition.
The findings include:
The facility's policy titled: "Case Consultations," states:
"Each patient 's progress is to be reviewed at least once during each inpatient rehab admission and at least quarterly for each partial/out-patient level of care using the interdisciplinary team approach. More frequent case consultations should be initiated if the client's response to treatment necessitates it."
On October 3, 2011, four client records requiring documentation of a case consultation were reviewed. The facility did not document a case consultation according to their policy in three of four records reviewed, specifically, client records # 4, 6, and 7. Also, the facility did not document a case consultation that included documentation of a summary and disposition in three of four records reviewed, specifically, client records # 4, 6, and 7.
Client # 4 was admitted June 6, 2011 and was due a case consultation on September 30, 2011. However, the case consultation in client record # 4 was dated July 25, 2011, but was incomplete and indicated that the case consultation was pending. Also, the case consultation did include documentation of a summary and disposition.
Client # 6 was admitted May 10, 2011 and was due a case consultation on August 31, 2011. However, the case consultation in client record # 6 was dated June 22, 2011, but was incomplete and indicated that the case consultation was pending. Also, the case consultation did include documentation of a summary and disposition.
Client # 7 was admitted April 4, 2011 and was due a case consultation on July 31, 2011. However, the case consultation in client record # 7 was dated May 18, 2011, but was incomplete and indicated that the case consultation was pending. Also, the case consultation did include documentation of a summary and disposition.
During an ongoing dialogue with the facility director conducted on October 3, 2011 from approximately 2:00 P.M. to 3:00 P.M., the findings were confirmed.
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Plan of Correction
In a meeting, on 10/3/11, the Program Manager reminded all counselors of the need to complete a Case Consultation at least quarterly for all patients, and that it needs to include documentation of a summary and disposition of the case. The Program Manager will randomly monitor patient charts to ensure compliance. Oversight will be provided by the Clinical Director. Also, the Quality Assurance Assistant will randomly monitor patient charts 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 a discharge summary.
The findings include:
The facility's policy titled: "Discharge/Transfer/Aftercare Documentation," states:
"The Discharge Summary provides accurate discharge status information to aftercare providers in a timely fashion (within one week from date of discharge)."
On October 3, 2011, three client records requiring documentation of a discharge summary were reviewed. The facility did not document a discharge summary in three of three records reviewed, specifically, client records # 5, 6, and 7.
Client # 5 was admitted April 11, 2011 and was discharged September 21, 2011. The discharge summary for client # 5 was due September 28, 2011; however, client record # 5 did not include documentation of a discharge summary as of October 3, 2011.
Client # 6 was admitted May 10, 2011 and was discharged August 20, 2011. The discharge summary for client # 6 was due August 27, 2011; however, client record # 6 did not include documentation of a discharge summary as of October 3, 2011.
Client # 7 was admitted April 4, 2011 and was discharged September 12, 2011. The discharge summary for client # 7 was due September 19, 2011; however, client record # 7 did not include documentation of a discharge summary as of October 3, 2011.
During an ongoing dialogue with the facility director conducted on October 3, 2011 from approximately 2:00 P.M. to 3:00 P.M., the findings were confirmed.
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Plan of Correction
In a meeting, on 1/3/11, the Program Manager reminded all counselors of the need to complete a Discharge Summary within one week of discharge. The Program Manager will randomly monitor patient charts to ensure that Discharge Summaries are documented in accordance with Livengrin's policy and procedures for all patients. The Quality Management Assistant will randomly monitor patient charts to ensure that Discharge Summaries are documented in accordance with livengrin's policy and procedures for all patients. Discharge Summaries will be completed for patients 5,6 and 7. Oversight will be provided by the Clinical Director. |
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.
The findings include:
The facility's policy titled: "Patient Follow-Up," states:
"If the patient is successfully discharged and has completed treatment, attempt to contact the patient within 30 days of discharge to ascertain the patient's status in recovery. Document this information (successful or unsuccessful contact/outcome) in the patient's chart."
On October 3, 2011, one client record requiring documentation of follow-up information was reviewed. The facility did not document follow-up information in one of one record reviewed, specifically, client record # 6.
Client # 6 was admitted May 10, 2011 and was successfully discharged August 20, 2011. The follow-up information for client # 6 was due September 19, 2011; however, client record # 6 did not include documentation of follow-up information as of October 3, 2011.
During an ongoing dialogue with the facility director conducted on October 3, 2011 from approximately 2:00 P.M. to 3:00 P.M., the findings were confirmed.
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Plan of Correction
In a meeting, on 10/3/11, the Program Manager reminded all counselors of the need to contact a patient who was successfully discharged and had completed treatment within thirty days of discharge to ascertain the patients' status in recovery. The Program Manager will randomly monitor patient charts to ensure that follow-up calls are documented in accordance with Livengrin's policy and procedures. The Quality Assurance Assistant will randomly monitor patient charts to ensure that follow-up calls are documented in accordance with Livengrin's policy and procedures. A follow-up call will be made to patient #6. Oversight will be provided by the Clinical Director. |