INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8, 2024, 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information disclosed in thirteen out of thirteen records.
The facility failed to ensure the client signed consent to release information forms to the funding source contained the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Vice President and Compliance Specialist have reviewed and updated the language on the consent form in question to specify what information is to be released. Senior Vice President will ensure future revisions on the form include specific information to be released is more specific. Senior Vice President has sent a list of all active patients to the Program Manager, the Program Manager will ensure all active patients sign the new consent form when they arrive for their next appointment. Compliance Specialist will follow up weekly with Program Manager to obtain status update on the progress of getting new consents signed. The Program Manager will review all new patient consent forms to ensure accuracy. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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 and the facility's policies and procedures, the facility failed to document a psychosocial evaluation by the third treatment session, in two of three applicable records reviewed.
Client # 2 was admitted on January 18, 2024 and was active at the time of the inspection. The psychosocial evaluation was due to be completed by January 26, 2024; however, it was not completed until February 6, 2024.
Client # 3 was admitted on July 17, 2023 and was discharged on August 3, 2023. The record did not contain a psychosocial evaluation.
This is a repeat citation from the March 16, 2023 annual licensing renewal inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued supervision. |
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:
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Observations
Based on a review of client records and the facility ' s policies and procedures, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client by the seventh treatment session, per the facility policy, in four of five applicable records reviewed.
Client # 1 was admitted on January 23, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan dated January 26, 2024, did not include documentation that the plan was completed with the client.
Client # 2 was admitted on January 18, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed on January 29, 2024; however, it was not completed until February 5, 2024.
Client # 3 was admitted on July 17, 2023 and was discharged on August 3, 2023. The individual treatment and rehabilitation plan was due to be completed by July 26, 2023; however, it was not completed until August 1, 2023.
Client # 7 was admitted on November 20, 2023 and was discharged on December 22, 2023. The individual treatment and rehabilitation plan was due to be completed by December 11, 2023; however, it was not completed until December 19, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued supervision. |
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 a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every thirty days in one of two applicable client records reviewed.
Client # 4 was admitted on July 21, 2023 and was discharged on September 13, 2023. The comprehensive treatment plan was completed on July 31, 2023, and the treatment plan update was due no later than August 31, 2023; however, no treatment plan updates were completed prior to the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager created new documentation tracking form for counselors. Discussed documentation due dates during staff meeting. Program Manager will monitor compliance through chart audits. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes prior to level of care change, per the facility's policy, in one of three applicable records reviewed.
Client # 3 was admitted on July 17, 2023 and was discharged on August 3, 2023. The record did not contain documentation of a case consultation note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued supervision. Program Manager has offered additional options for case consultations to be reviewed during supervision sessions. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within 24 hours of the date of service, per the facility's policy, in three of seven records reviewed.
Client # 1 was admitted on January 23, 2024 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on January 26, 2024, that was not completed by the time of the inspection.
Client # 2 was admitted on January 18, 2024 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on January 30, 2024, that was not completed by the time of the inspection.
Client # 4 was admitted on July 21, 2023 and was discharged on September 13, 2023. The record contained a blank progress note for an individual session occurring on August 28, 2023, that was not completed by the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued supervision. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary within seven days of discharge, per facility policy, in three of five applicable records reviewed.
Client # 3 was admitted on July 17, 2023 and was discharged on August 3, 2023. The record did not contain a discharge summary.
Client # 6 was admitted on June 29, 2023 and was discharged on July 28, 2023. The record did not contain a discharge summary.
Client # 7 was admitted on November 20, 2023 and was discharged on December 22, 2023. The record did not contain a discharge summary.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued 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 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 30 days of discharge, per facility policy, in two of five applicable records reviewed.
Client # 4 was admitted on July 21, 2023 and was discharged on September 13, 2023. The record did not contain documentation of follow-up information.
Client # 6 was admitted on June 29, 2023 and was discharged on July 28, 2023. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames for follow ups. The Program Manager created a new tracking form for counselors to utilize to determine due dates of follow ups. Program Manager will monitor compliance through chart audits and continued supervision. |
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 and the facility ' s policies and procedures, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client by the seventh treatment session, per the facility policy, in three of seven applicable records reviewed.
Client # 10 was admitted on May 10, 2023 and was discharged on August 11, 2023. The individual treatment and rehabilitation plan was due to be completed on June 21, 2023; however, it was not completed until July 12, 2023.
Client # 11 was admitted on May 30, 2023 and was discharged on December 7, 2023. The individual treatment and rehabilitation plan was due to be completed by June 13, 2023; however, it was not completed until October 13, 2023.
Client # 14 was admitted on August 24, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 4, 2023; however, it was not completed until October 11, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued 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 a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every 90 days, per the facility's policy, in three of seven applicable records reviewed.
Client # 10 was admitted on May 10, 2023 and was discharged on August 11, 2023. The case consultation note was due to be completed by August 10, 2023; however, it was not completed until August 21, 2023.
Client # 12 was admitted on August 9, 2023 and was active at the time of the inspection. The record did not contain documentation of a case consultation note.
Client # 14 was admitted on August 24, 2023 and was active at the time of the inspection. The record did not contain documentation of a case consultation note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent supervision the Program Manager discussed the time frames around documentation. Additionally, the Program Manager created a new tracking form for counselors to utilize to determine due dates of documentation. Program Manager will monitor compliance through chart audits and continued supervision. |