INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The organization was granted an extension on it's financial audit by the IRS, expected completion 6/30/2023. This extension was requested due to a change in staff. Proof of the IRS extension was provided at the time of the audit. If this should happen in the future the organization will request an extention from the department as well. The Controller and Finance consultant are responsible to oversee this process. |
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.
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Observations
Based on a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four records reviewed.
Client #1 was admitted to the partial hospitalization level of care on September 26, 2022 and was discharged on October 10, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on September 26, 2022 and October 7, 2022, with no client signed consent to release information form signed by the client.
Client #8 was admitted to the outpatient level of care on October 10, 2022 and was discharged on January 19, 2023. The record contained documentation that personally identifying information was released to the Department of Human Services on January 3, 2023, with no client signed consent to release information form signed by the client.
Client #11 was admitted to the outpatient level of care on January 3, 2022 and was discharged on February 6, 2023. The client signed consent to release information form to the funding source expired on December 30, 2022 and the record contained evidence of billing on January 3, 2023 and January 10, 2023.
Client #13 was admitted to the outpatient level of care on June 9, 2022 and was discharged on February 6, 2023. The consent to release information form to the funding source was signed by the client on November 25, 2022, and the record contained documentation of billing prior to that date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has added a new consent for DHS/Promise to avoid this from happening in the future. Program Manager will ensure staff use the appropriate consent through random chart audits. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one applicable record reviewed.
Client #11 was admitted to the outpatient level of care on January 3, 2022 and was therapeutically discharged on February 6, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-educated on the requirement to send termination letters when an a patient has been involuntarily discharged from the program. Program Manager will monitor compliance through random chart audits. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of seven client records, the facility failed to ensure that counseling was provided to clients on a regular and scheduled basis, that included individual counseling, at least twice weekly in three records reviewed.
Client #1 was admitted to the partial hospitalization level of care on September 26, 2022 and was discharged on October 10, 2022. The record contained documentation of only one individual counseling session offered the treatment week of October 3, 2022 through October 9, 2022.
Client #2 was admitted to the partial hospitalization level of care on August 17, 2022 and was discharged on September 1, 2022. The record contained documentation of only one individual counseling session offered the treatment week of August 24, 2022 through August 30, 2022.
Client #3 was admitted to the partial hospitalization level of care on December 20, 2022 and was discharged on January 3, 2023. The record contained documentation of only one individual counseling session offered the treatment week of December 20, 2022 through December 26, 2022.
This is a repeat citation from the March 10, 2022, March 11, 2021, March 13, 2020 and March 8, 2019 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-educated on requirement to perform two individual session per week during PHP level of care. Program Manager will monitor compliance through random chart audits. |
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 ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in three of six applicable client records reviewed.
Client #9 was admitted to the outpatient level of care on September 1, 2022 and was active at the time of the inspection. A treatment plan update was signed as completed by the client on October 18, 2022, and the next treatment plan update was due no later than December 18, 2022; however, the treatment plan update was not completed until January 11, 2023.
Client #10 was admitted to the outpatient level of care on April 25, 2022 and was active at the time of the inspection. A treatment plan update was signed as completed by the client on August 22, 2022, and the next treatment plan update was due no later than October 22, 2022; however, the treatment plan update was not completed until November 30, 2022.
Client #11 was admitted to the outpatient level of care on January 3, 2022 and was discharged on February 6, 2023. A treatment plan update was signed as completed by the client on July 24, 2022, and the next treatment plan update was due no later than September 24, 2022; however, the treatment plan update was not completed until October 24, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-educated on defined time frames for treatment plan completion. Program Manager will monitor compliance through random chart audits. |
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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information within seven days of discharge, per facility policy, in four of four applicable records reviewed.
Client #11 was admitted to the outpatient level of care on January 3, 2022 and was discharged on February 6, 2023. There was no documentation of follow-up information in the record.
Client #12 was admitted to the outpatient level of care on January 3, 2023 and was discharged on February 3, 2023. There was no documentation of follow-up information in the record.
Client #13 was admitted to the outpatient level of care on June 9, 2022 and was discharged on February 6, 2023. There was no documentation of follow-up information in the record.
Client #14 was admitted to the outpatient level of care on May 12, 2022 and was discharged on August 22, 2022. The follow-up information was documented on September 7, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has revised it's internal policy to allow additional time for follow up completion. Staff were educated on the policy revision and the requirement to perform follow ups. Program Manager will monitor compliance through random chart audits. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to assure that clients, admitted to the partial hospitalization activity, received individual counseling services at least twice a week were submitted and approved by the Department for the March 10, 2022, March 11, 2021, March 13, 2020, and March 8, 2019, annual licensing inspections.
During the March 2, 2023, annual licensing inspection it was determined that the facility again failed to follow the approved plan of correction resulting in an additional repeat citation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Manager, in conjunction with the Director of Outpatient services, will ensure the plan of correction is implemented by completing random chart audits. |