INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2014 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors participated in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position.
The findings include:
One personnel record was reviewed for the position of clinical supervisor on January 13, 2014. The facility failed to provide documentation to verify that employee # 3 participated in monthly supervision for the first 6 months of employment.
Employee # 3 was hired for the position of clinical supervisor on March 6, 2013 and was required to participate in documented monthly supervision until September 6, 2013. The facility failed to provide documentation to verify that the clinical supervisor participated in monthly supervision with their supervisor between March 6, 2013 and September 6, 2013.
The findings were reviewed with the Director of Quality Assurance.
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Plan of Correction
Supervision for employee #3 has been documented and placed in the supervision log. The Vice-president of Outpatient Services will ensure that documentation of newly hired clinical supervisors will be completed and placed in the personel file in a timely manner. This documentation will be completed on a monthly basis during the first 6 months of hire date and demonstrate that duties and performance issues were discussed. The Director of QA will audit the clinical supervision log on a monthly basis to ensure that this standard is in full compliance.
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709.91(b)(6) LICENSURE Intake and admission
709.91. 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, the facility failed to document a psychosocial evaluation in two of five records reviewed.
The findings include:
Five client records requiring documentation of a psychosocial evaluation were reviewed on January 22, 2014. The facility failed to document a psychosocial evaluation in client records # 3 and 4.
Client # 3 was admitted to the program on 9/19/13. The facility failed to document a psychosocial evaluation in client record # 3.
Client # 4 was admitted to the program on 4/16/13. The facility failed to document a psychosocial evaluation in client record # 4.
The Program Manager reviewed the record and confirmed the findings.
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Plan of Correction
Training on completion of psychosocial evaluations will begin immediately and be ongoing. The program manager of the Allentown location will have an inserivce training which outlines the proper documentation standards for completion of a psychosocial assessment. The training will be completed on 2/21/2014. The Director of QA will perform random, monthly charts audits at the Allentown location until the center has met 100% compliance.
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record that included case consultation notes and an aftercare plan in two of five client records.
The findings include:
Five client records were reviewed on January 22, 2014. The facility failed to document case consultation notes and an aftercare plan in client records # 4 and 5.
Client # 4 was admitted on 4/16/13 and successfully discharged on 8/25/13. The facility failed to document a complete client record that included a case consultation note and an aftercare plan for client # 4.
Client # 5 was admitted on 2/25/13 and successfully discharged on 7/31/13. The facility failed to document a complete client record that included a case consultation note and an aftercare plan for client # 5.
The Program Manager reviewed the records and confirmed the findings.
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Plan of Correction
Training on the completion of case consults will begin immediately and be ongoing. The program manager of the Allentown office will conduct an in-service training on 2/21/2014 regarding documentation of case consults and aftercare plans. All allentown staff will attend this training. The Director of QA will conduct monthly, random chart audits until the Allentown center has reached 100% compliance with the standard.
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