INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 12, 2020 through March 13, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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.
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on the review of personnel records, the facility failed to provide documentation that an individual training plan, for the current training year, was appropriate to the employee's skill level in one of six personnel records reviewed.Employee # 2 was hired as the Facility Director on September 10, 2018. The individual training plan, signed by the employee and supervisor on December 18, 2019 only listed CPR training.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Individual training plans will be completed on an annual basis. Human Resources will create a comprehensive training plan that will be shared with supervisors in June of each year. Supervisors will collaborate with each employee to develop their training plan. Human Resources will ensure that all training plans are completed and returned by June 30th of each year for the following fiscal year.
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on the review of the project's policy and procedure manual and client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients. The procedure manual states that progress notes must be completed within 24 hours of the date of service; however, there were several progress notes entered into the record two weeks after the sessions were conducted in 7 of 14 client records reviewed.Client # 3 was admitted to the partial hospitalization level of care on June 10, 2019 was discharged on July 2, 2019. Client # 4 was admitted to the partial hospitalization level of care on September 10, 2019 and was discharged on September 26, 2019.Client # 6 was admitted to the partial hospitalization level of care on April 11, 2019 and was discharged on May 1, 2019.Client # 7 was admitted to the partial hospitalization level of care on December 31, 2019 and was discharged on January 17, 2020.Client # 8 was admitted to the outpatient level of care on January 3, 2020 and was active at the time of the inspection.Client # 9 was admitted to the outpatient level of care on September 27, 2019 and was active at the time of the inspection.Client # 12 was admitted to the outpatient level of care on May 1, 2019 and was discharged on August 9, 2019.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Documentation procedures were reviewed with the staff of this facility at a staff meeting immediately following exit interview on 3/13/2020.
One clinician was responsible for late documentation of all 7 charts across both PHP and outpatient level of care. Corrective Action has been taken.
Livengrin Foundation, Inc. is in the process of reviewing and revising all policies and procedures.
After the emergency declaration is lifted, the Quality Improvement Coordinator will be training staff during weekly staff meetings and supporting Program Managers with compliance reporting. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on the review of client records, the facility failed to document the name of a person, agency or organization to whom the disclosure was to be made to on a consent form in 4 of 14 client records.Client # 5 was admitted to the partial hospitalization level of care on July 16, 2019 and was discharged August 24, 2019. There were consent to release information forms to a managed care organization and an EAP signed and dated by the client on June 21, 2019 and June 29, 2019, respectively; however, both of the consent forms did not include the specific name of the person, agency or organization.Client # 6 was admitted to the partial hospitalization level of care on April 11, 2019 and was discharged on May 1, 2019. There was a consent to release information form to a medical provider signed and dated by the client on April 11, 2019; however, the consent form did not include the specific name of the person, agency or organization.Client # 10 was admitted to the outpatient level of care on March 11, 2019 and was active at the time of the inspection. There were consent to release information forms to a pharmacy, a medical provider and an EAP, all signed and dated by the client on February 4, 2019; however, all three of the consent forms did not include the specific name of the person, agency or organization.Client # 12 was admitted to the outpatient level of care on May 1, 2019 and was discharged on August 9, 2019. There was a consent to release information form to a medical provider signed and dated by the client on April 11, 2019; however, the consent form did not include the specific name of the person, agency or organization.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Staff members have all been assigned 42 CFR training through Relias, Livengrin's learning management system. All managers will review consent requirements during staff meetings. Consent requirements fact sheets aligned with PA code 255.5 and the required elements of consent have been distributed to managers, supervisors and directors. Consents will be reviewed by Livengrin Admissions staff, Clinical Counseling Staff and Office Managers at admission and each subsequent level of care to determine necessary consents for all stakeholders have been obtained.
All consents for active clients have been reviewed and updated. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on a consent to release information form in 2 of 14 client records.Client # 3 was admitted to the partial hospitalization level of care on June 10, 2019 and was discharged on July 2, 2019. There was a consent to release information form to a probation officer signed and dated by the client on June 10, 2019; however, the consent form did not include a purpose for the disclosure of information.Client # 8 was admitted to the outpatient level of care on January 3, 2020 and was active at the time of the inspection. There was a consent to release information form to a probation officer signed and dated by the client on June 10, 2019; however, the consent form did not include a purpose for the disclosure of information.These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
Staff members have all been assigned 42 CFR training through Relias, Livengrin's learning management system. All managers will review consent requirements during staff meetings. Consent requirements fact sheets aligned with PA code 255.5 and the required elements of consent have been distributed to managers, supervisors and directors. Consents will be reviewed by Livengrin Admissions staff, Clinical Counseling Staff and Office Managers at admission and each subsequent level of care to determine necessary consents for all stakeholders have been obtained.
All consents for Client 8 have been reviewed and updated in the EHR.
|
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in 1 of 14 client records reviewed.Client # 1 was admitted on March 3, 2020 and was active at the time of the inspection.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Civil Rights Consent form has been sent to the Office of Civil Rights for review. Post Emergency Declaration, The Quality Improvement Coordinator will attend staff meetings to train all staff on the required consents. During the emergency declaration, a list of all required signed consents has been distributed to the managers, supervisors and directors of all departments.
The Civil Rights attestation has been signed and updated in the active patient's chart.
|
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on the review of unusual incidents, the facility failed to notify the Department within 3 days following an unusual incident, which required the presence of police and ambulance personnel on November 12, 2019.These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
Quality Improvement Coordinator has reviewed the Licensing Alert 02-2018 Dated December 24, 2018.
Staff have been received an electronic copy of the Unusual Incident Reporting Policy including 24 hours timeline. Policy has been changed to update Program Manager and Director of Outpatient Services will be copied on email to RA-DAAPI_Division@pa.gov.
All incident reports matching the 5 categories that must be reported to DDAP will be reported to DDAP by the Quality Improvement Coordinator. Emailed copies will be kept on file in the Quality Department.
|
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
|
Observations
Based on the review of client records, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in two of seven applicable client records reviewed. Additionally, the facility failed to document which types of services and the frequency the client was to receive those services on the client's individual treatment plan in one of five applicable client records.Client # 3 was admitted on June 10, 2019 and was discharged on July 2, 2019. The record did not contain a comprehensive treatment plan.Client # 4 was admitted on September 10, 2019 and was discharged on September 26, 2019. The comprehensive treatment plan was dated September 13, 2019. The comprehensive treatment plan did not include long term goals, the type and frequency of services or supportive services to be provided.Client # 7 was admitted on December 31, 2019 and was discharged on January 17, 2020. The record did not contain a comprehensive treatment plan.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Manager has comprehensively reviewed the requirements of treatment plans during weekly staff meetings.
One clinician has been subject to corrective action.
Program Managers have been instructed to utilize embedded reports in Aura titled Patients with Expiring Treatment Plans and Patients without Treatment Plans weekly. The Quality Department will continue to monitor chart compliance monthly using a random sample. The sample size will increase from 5 charts per month to 10 charts.
Any clinician found to be non compliant with Treatment Planning requirements may be subject to corrective action. |
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.
|
Observations
Based on the review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice a week, in four of six applicable client records reviewed in the partial hospitalization activity. Client # 3 was admitted on June 10, 2019 and was discharged on July 2, 2019. Documentation of two individual sessions was not completed for the weeks of June 16, 2019 to June 22, 2019 and June 23, 2019 to June 29, 2019.Client # 4 was admitted on September 10, 2019 and was discharged on September 26, 2019. Documentation of two individual sessions was not completed for the weeks of September 15, 2019 to September 21, 2019 and September 22, 2019 to September 28, 2019.Client # 6 was admitted on April 11, 2019 and was discharged on May 1, 2019. Documentation of two individual sessions was not completed for the weeks of April 14, 2019 to April 20, 2019 and April 21, 2019 to April 27, 2019.Client # 7 was admitted on December 31, 2019 and was discharged on January 17, 2020. Documentation of one individual session per week was not completed for the week of January 5, 2020 to January 11, 2020.These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Review of Partial Hospitalization Program Regulations has been reviewed with outpatient site staff.
One clinician has been subject to corrective action.
Program Manager will monitor documentation to include 5 groups and 2 individual sessions per week. Missed sessions will be documented in the chart with reason.
The Quality Department will continue to monitor charts monthly using a random sample. The sample size will increase from 5 charts per month to 10 charts. Results will continue to be dispersed to Program Manager.
Clinicians found to be non compliant with the regulation may be subject to corrective action by their immediate supervisor. |
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:
|
Observations
Based on the review of client records, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in one of seven applicable client records reviewed. Additionally, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in three of seven client records.Client # 8 was admitted on January 3, 2020 and was active at the time of the inspection. The written procedure manual stated that the master treatment plan must be completed by the seventh session. The seventh session counseling session occurred on January 9, 2020; however, the treatment plan was not completed until February 19, 2020. Client # 9 was admitted on September 27, 2020 and was active at the time of the inspection. The written procedure manual stated that the master treatment plan must be completed by the seventh session. The seventh session counseling session occurred on October 8, 2019; however, the treatment plan was not completed until October 24, 2019 Client # 12 was admitted on May 1, 2019 and was discharged August 9, 2019. The written procedure manual stated that the master treatment plan must be completed by the seventh session. The seventh session counseling session occurred on May 13, 2019; however, the treatment plan was not developed until August 9, 2019. Additionally, the comprehensive treatment plan did not contain a client signature and there was no other documentation that stated the plan was developed with the client.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Manager reviewed the time frames for treatment plans with staff during weekly staff meeting.
One clinician has been subject to corrective actions due to non-compliance of charts cited throughout the DDAP chart audits.
Program Managers are pulling embedded Aura Reports: Patients with Expiring Treatment Plans and Patients without existing treatment plans weekly to address compliance of treatment planning and treatment plan updating.
The Quality Department will continue to monitor chart compliance monthly using a random sample. The sample size will be increased from 5 charts per month to 10 charts per month.
Any clinician failing to maintain chart compliance may be subject to corrective action. |
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 the review of client records, the facility failed to provide treatment plan updates within the regulatory timeframe in three of five applicable client records reviewed.Client # 9 was admitted on September 27, 2019 and was active at the time of the inspection. A treatment plan update was completed on December 18, 2019 with an update due no later than February 18, 2020; however, the update was not completed until March 4, 2020.Client # 13 was admitted on May 30, 2019 and was discharged on September 25, 2019. The comprehensive treatment plan was dated June 6, 2019 with an update due no later than August 6, 2019; however, no update was completed prior to discharge.Client # 14 was admitted on March 20, 2019 and was discharged on January 15, 2020. A treatment plan update was completed on May 2, 2019 with an update due no later than July 2, 2019; however, the update was not completed until October 9, 2019.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Manager reviewed the time frames for treatment plans and updates with staff during weekly staff meeting.
One clinician has been subject to corrective actions due to non-compliance of charts cited throughout the DDAP chart audits.
Program Managers are pulling embedded Aura Reports: Patients with Expiring Treatment Plans and Patients without existing treatment plans weekly to address compliance of treatment planning and treatment plan updating.
The Quality Department will continue to monitor chart compliance monthly using a random sample. The sample size will be increased from 5 charts per month to 10 charts per month.
Any clinician failing to maintain chart compliance may be subject to corrective action. |