INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Livengrin Foundation, Inc. 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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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on the review of partial hospitalization client records, the facility failed to review and update treatment and rehabilitation plans at least every 30 days in one of one applicable record reviewed.
Client #4 was admitted on September 5, 2024, and was discharged on October 14, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on September 9, 2024, and the update was due no later than October 9, 2024; however, there was no updated plan documented in the record at the time of the licensing inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During supervision the team members were re-educated on the proper documentation protocols. The Program Manager has added this to the audit checklist and will monitor during monthly chart audit completion. Program Manager will address issues of noncompliance during individual supervision. |
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 the review of client records, the project failed to document two weekly individual counseling sessions in four of seven partial hospitalization clients reviewed.
Client #2 was admitted on February 10, 2025 and was an active client at the time of the inspection. The project only documented one individual counseling session for the week of February 16, 2025 through February 22, 2025.
Client #3 was admitted on April 22, 2024 and was discharged on June 5, 2024. The project only documented one individual counseling session for the weeks of April 28, 2024 through May 4, 2024, May 12, 2024 through May 18, 2024 and May 19, 2024 through May 25, 2024. Additionally, there were no individual counseling sessions documented the week of May 26, 2024 through June 1, 2024.
Client #6 was admitted on May 29, 2024 and was discharged on June 20, 2024. The project only documented one individual counseling session for the week of June 2, 2024 through June 8, 2024. Additionally, there were no individual counseling sessions documented the week June 9, 2024 through June 15, 2024.
Client #7 was admitted on March 27, 2024 and was discharged on April 19, 2024. The project only documented one individual counseling session for the weeks of March 31, 2024 through April 6, 2024 and April 7, 2024 through April 13, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During supervision the team members were re-educated on the proper documentation protocols. Program Manager reviewed with staff that patient absenteeism (cancel/call off) when scheduled for an individual sessions should be documented in the chart. The Program Manager has added this to the audit checklist and will monitor during monthly chart audit completion. Program Manager will address issues of noncompliance during individual supervision. |
709.83(a)(11) LICENSURE Client records
709.83. 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 the review of partial hospitalization client records and the project ' s policies and procedures, the project failed to document a complete client record on an individual that included follow-up information 30 days after the client ' s discharge in two of four applicable client records reviewed.
Client #3 was admitted on April 22, 2024 and was discharged on June 5, 2024. Per the projects policies and procedures, follow-up information was to be documented no later than July 5, 2024; however, follow-up information was not documented in the record until August 1, 2025.
Client #6 was admitted on May 29, 2024 and was discharged on June 20, 2024. Per the projects policies and procedures, follow-up information was to be documented no later than July 20, 2024; however, follow-up information was not documented in the record until August 1, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During supervision the team members were re-educated on the proper documentation protocols. The Program Manager and Office Manager will work in tandum to perform follow up calls on a weekly basis. Program Manager will review weekly with Office Manager to ensure follow up calls are completed in a timely manner. |
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 the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of five applicable records reviewed.
Client # 13 was admitted on March 11, 2024 and was discharged on December 26, 2024. An updated treatment and rehabilitation plan was documented in the record on July 26, 2024, and the next update was due no later than September 26, 2024; however, the updated treatment plan was not documented in the record until October 11, 2024.
Client # 14 was admitted on May 15, 2024 and was discharged on October 15, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on May 23, 2024, and the update was due no later than July 23, 2024; however, there was no updated plan documented in the record at the time of the licensing inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During supervision the team members were re-educated on the proper documentation protocols. The Program Manager has added this to the audit checklist and will monitor during monthly chart audit completion. Program Manager will address issues of noncompliance during individual supervision. |
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 the review of outpatient client records and the project ' s policies and procedures, the project failed to document a complete client record on an individual that included case consultation notes in three of three applicable client records reviewed.
Client #9 was admitted on June 19, 2024 and was an active client at the time of the inspection. A case consultation note was not documented in the client record at the change in level of care and every 90 days after, per facility policy.
Client # 13 was admitted on March 11, 2024 and was discharged on December 26, 2024. A case consultation note was not documented in the client record at the change in level of care and every 90 days after, per facility policy.
Client # 14 was admitted on May 15, 2024 and was discharged on October 15, 2024. A case consultation note was not documented in the client record at the change in level of care and every 90 days after, per facility policy.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During supervision the team members were re-educated on the proper documentation protocols. The Program Manager has added this to the audit checklist and will monitor during monthly chart audit completion. Program Manager will address issues of noncompliance during individual supervision. |
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 the review of outpatient client records and the project ' s policies and procedures, the project failed to document a complete client record on an individual that included follow-up information 30 days after the client ' s discharge, per facility policy, in three of four applicable client records reviewed.
Client #11 was admitted on September 3, 2024 and was discharged on November 1, 2024. Per the projects policies and procedures, follow-up information was to be documented no later than December 1, 2024; however, the follow-up information was not documented in the record until January 27, 2024.
Client # 12 was admitted on September 9, 2024 and was discharged on October 14, 2024. Follow-up information was not documented in the record at the time of the inspection.
Client # 14 was admitted on May 15, 2024 and was discharged on October 15, 2024. Follow-up information was not documented in the record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During supervision the team members were re-educated on the proper documentation protocols. The Program Manager and Office Manager will work in tandum to perform follow up calls on a weekly basis. Program Manager will review weekly with Office Manager to ensure follow up calls are completed in a timely manner. |