INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection with an administrative site inspection and record review conducted on March 4-8, 2013 and the physical plant inspection ending on March 14, 2013 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:
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Plan of Correction
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations as required by facility policy and regulation in two of five personnel records reviewed.
The findings include:
Five personnel records requiring documentation of an annual evaluation were reviewed on March 4, 2013. Per facility policy, performance evaluations are conducted at three months and annually thereafter. The facility failed to document annual performance evaluations in two of five personnel records reviewed, specifically records # 1 and 2.
Employee #1 was hired as the Project Director on October 26, 1987. The facility failed to document an annual performance evaluation for the past 2 years.
Employee #2 was hired as the Facility Director on September 3, 2001. The facility failed to document an annual performance evaluation for 2012. The last annual performance evaluation was completed on December 10, 2010.
The findings were confirmed by the Director of Compliance and Licensing.
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Plan of Correction
The Human Resources Director will ensure that annual evaluations are sent to supervisors and returned. The Director of Compliance and Licensing will be responsible for oversight, by confirming on a monthly basis that all annual evaluations are sent and returned. #2 evaluation has been sent to supervisor and returned to Human Resources, confirmed by the Director of Compliance and Licensing. #1 - the President/CEO will meet with the Board of Directors on 4/25/13. His evaluation with be completed and sent to Human Resources. The Director of Compliance and Licensing will confirm that it has been sent to Human Resources. |
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 document they informed the client of their rights upon admission in three of five records.
The findings include:
Facility policy titled "Patient Orientation" states that orientation will occur when the admission process has been completed and prior to the patient attending his/her first scheduled activity.
Five client records requiring documentation of being informed of the client rights were reviewed March 6-7, 2013. The facility failed to document they informed the client of their rights upon admission in three of five records, specifically records # 3, 4, and 5.
Client # 3 was admitted on 10/31/12 and was still an active client at the time of the inspection. The facility failed to document they informed the client of their rights upon admission in this client record. The client rights were documented as being reviewed with client # 3 on 12/11/12.
Client # 4 was admitted on 12/28/12 and was discharged on 1/29/13. The facility failed to document they informed the client of their rights upon admission in this client record. The client rights were documented as being reviewed with client # 4 on 1/22/13.
Client # 5 was admitted on 7/17/12 and was discharged on 9/4/12. This record did not contain any documentation that client rights were reviewed with client # 5.
The findings were confirmed by the Director of Compliance and Licensing.
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Plan of Correction
The Program Manager met with all counselors to remind them that all patients need to be informed of their rights. All active patients that were cited will be informed of their rights. The Program Manager will review the charts to ensure that the patients were informed of their rights. The Director of Compliance and Licensing will ensure that all active patients were informed of their rights. The Quality Assurance Assistant will randomly monitor patient charts on a monthly basis, to ensure compliance. The Report will be sent to the Program Manager and their supervisor. Oversight will be provided by the Director of Compliance and Licensing. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a client medical history, that included family medical history in five of seven records reviewed.
The findings include:
Seven client records requiring documenting of a family medical history were reviewed March 6-7, 2013. The facility failed to document family medical history in five of seven records reviewed, specifically records # 1, 3, 4, and 5.
Client # 1 was admitted on 12/4/12 and was still an active client at the time of inspection. The facility failed to document a family medical history in this client record as of 3/14/2013.
Client # 3 was admitted on 10/31/12 and was still an active client at the time of inspection. The facility failed to document a family medical history in this client record as of 3/14/2013.
Client # 4 was admitted on 12/28/12 and and was discharged on 1/29/13. The facility failed to document a family medical history in this client record as of 3/14/2013.
Client # 5 was admitted on 7/17/12 and was discharged on 9/4/12. The facility failed to document a family medical history in this client record as of 3/14/2013.
The findings were confirmed by the Director of Compliance and Licensing.
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Plan of Correction
In a meeting, on 3/22/13, the Program Manager reminded all counselors of the need to include family medical history in the medical history. All active patients that were cited need to be corrected. The Program Manager will review the charts to ensure they were corrected. The Director of
Compliance and Licensing will confirm with the Program Manager that they have been corrected. The Quality Assurance Assistant will randomly monitor charts on a monthly basis, to ensure compliance. The monthly report will be sent to the Program Manager and their supervisor. Oversight will be provided by the Director of Compliance and Licensing. |