INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 2009 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 and a plan of correction is due on March 14, 2009.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to document that employee #3 completed the core curriculum in clinical supervision.
Findings:
Personnel records were reviewed on February 2 and 3, 2009. The core curriculum in clinical supervision was required for employee #3. The facility failed to document that employee #3, who was hired as clinical supervisor on April 7, 2008, completed the core curriculum in clinical supervision.
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Plan of Correction
The TQM Director will remind the Clinical Supervisor on 3/16/2009 of the need for her to attend the next available department clinical supervisor training. The Outpatient Director will ensure compliance. In the future, anyone hired as a Clinical Supervisor will attend the core curriculum training within six months of hire. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of administrative documentation, the facility failed to document an annual report to include a statement disclosing the names of officers, directors and principal shareholders.
Findings:
The facility ' s annual report was reviewed on February 2, 2009. The facility failed to include the names of officers, directors and principal shareholders in the annual report.
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Plan of Correction
The TQM Director will remind the PR Director of the need to disclose the names of officers, directors and principle shareholders in any subsequent annual reports. Compliance will be monitored by the tQM Director. |
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.
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Observations
Based on a an interview with the clinical supervisor, a review of administrative documentation and a review client records, the facility failed to complete clinical documentation within the stated timeframes of the projects policy and procedures manual.
Findings:
The project ' s policy and procedures manual states, client histories and psychosocial evaluations will be completed within 72 hours, and treatment plan updates will be completed every 30 days.
The facility ' s practice is to document client histories and psychosocial evaluations within 7 days of admission and treatment plan updates every 60 days.
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Plan of Correction
By 4/30/2009, the Clinical Director will amend the psychosocial evaluation policy to state that the psychosocial evaluation will be completed within seven days and treatment plan updates will be completed within sixty days for outpatient services. Compliance will be monitored by the Clinical Supervisor on a monthly basis. The Outpatient Director will be responsible for oversight. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review administrative documentation, the facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency medical and psychiatric coverage.
Findings:
Administrative documentation was reviewed on February 12, 2009. A written agreement with a licensed hospital or physician for 24-hour emergency medical and psychiatric coverage was required. The facility did not document a written agreement for 24-hour emergency medical and psychiatric coverage. The facility documented an agreement with Lehigh Valley Health Network, but the agreement did not state 24-hour emergency medical and psychiatric.
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Plan of Correction
By 5/15/2009, the Clinical Supervisor will obtain a written agreement with a licensed hospital or physician for 24 hour emergency medical and psychiatric coverage. The TQM Director will monitor compliance. The Outpatient Director will be responsible for oversight. |
709.28(c)(6) 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 shall be in writing and include, but not be limited to:
(6) Expiration date of the consent.
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Observations
Based on a review of client records, the facility failed to document the expiration date of the client ' s signed consent for the release of information in four of seven client records.
Findings:
Eleven client records were reviewed on February 12, 2009. An expiration date of the signed consent for the release client information was reviewed in seven client records. The facility did not document an expiration date on a release of information form in client records # 1, 2, 4, and 8.
Record # 1, release to Independence Blue Cross and Magellan, no expiration date
Record # 2, release to Aetna, family contact, primary care physician, social worker and LACP no expiration date.
Record # 4, release to Blue Cross, and Highmark Behavioral Health, no expiration date
Record # 8, release to CIGNA Behavioral Health and Family Contact, no expiration date
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Plan of Correction
In a meeting on 3/25/09, the Clinical Director will educate administrative and clinical staff of the need to comply with federal and state confidentiality regulations, including the fact that expiration dates are required for all releases. Compliance will be monitored by the Clinical Supervisor on a monthly basis. The Outpatient Director will be responsible for oversight. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on a review of client records the facility failed to document efforts towards informing clients of their rights in eleven of eleven client records.
Findings:
Eleven client records were reviewed on February 12, 2009. Documentation of the client ' s right to inspect his/her own record was required in eleven client records. The facility did not document the client ' s right to inspect his/her own record in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11.
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Plan of Correction
The TQM Director will add to the client rights document the right of the client to inspect his/her own records. Compliance will be monitored by the Project Director. Compliance with the amended document will be monitored by the Clinical Supervisor on a monthly basis. The Outpatient Director will be responsible for oversight. |
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 seven of seven client records.
Findings:
Eleven client records were reviewed on February 12, 2009. Psychosocial evaluations were required in seven client records. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4, 7, 8 and 9
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths, support systems, and coping mechanisms in client records # 1, 3, 4, 7 and 8.
The facility did not document a psychosocial evaluation to include the client ' s negative factors and attitude towards treatment in client records # 2, 3, 4, 7, 8.
The facility did not document a psychosocial evaluation within seven day of admission in client records 2 and 9.
Record # 2 admission date 12/18/08, psychosocial evaluation not documented at time of inspection.
Record #9 admission date 3/25/08, discharge date 6/12/08, psychosocial evaluation not documented at time of inspection.
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Plan of Correction
In a meeting on 3/25/09, the Clinical Supervisor will educate counselors of the need to complete a psychosocial evaluation for all patients that contains all required elements, including assets/strengths, support systems, coping mechanisms and negative factors. Compliance will be monitored by the Clinical Supervisor on a monthly basis. The Outpatient Director will be responsible for oversight. |
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, the facility failed to document an individual treatment and rehabilitation plan in ten of ten client records.
Findings:
Eleven client records were reviewed on February 12, 2009. An individual treatment and rehabilitation plan was required in ten client records.
The facility did not document individualized treatment plans in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 11.
The treatment plans documented in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 11 contained the same goals and were not based on the client ' s clinical summary.
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Plan of Correction
In a meeting on 3/25/09, the Clinical Supervisor will educate counselors about the requirement for an individualized treatment plan to be completed for each patient. Compliance will be monitored by the Clinical Supervisor on a monthly basis. The Outpatient Director will be responsible for oversight. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan to include type and frequency of treatment and rehabilitation services in six of eleven client records.
Findings:
Eleven client records were reviewed on February 12, 2009. Individual treatment plans were reviewed in eleven client records. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 1, 3, 4, 6, 7, 8 and 9.
Treatment plans did not address individual sessions or stated individual sessions " as needed " .
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Plan of Correction
In a meeting on 03/25/2009, the Clinical Supervisor will educate counselors about the requirement for individual treatment plans to include type and frequency of services. Compliance will be monitored by the Clinical Supervisor on a monthly basis. The Outpatient Director will be responsible for oversight. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment plan.
Findings:
Eleven client records were reviewed on February 12, 2009. Counseling session progress notes were not documented according to the individual treatment plan in client records # 2, 3, 4, 5, 6, 7, 8 and 9.
Record # 2, treatment plan states individual sessions 1x weekly, individual session progress notes documented 12/18/08.
Record # 3, treatment plan does not address individual session frequency. No Individual session progress notes documented.
Record # 4, treatment plan does not address individual session frequency. Individual session progress notes documented, 11/4/08, 11/10/08, 11/7/08, 12/2/08, 12/10/08, 12/17/08, 1/2/09 and 1/16/09.
Record # 5, treatment plan states individual sessions 1x weekly, individual session progress notes documented 6/10/08, 7/1/08, 7/15/08, 7/29/08 and 8/5/08
Record # 6, treatment plan states individual sessions as needed, individual session progress note documented 9/25/08.
Record # 7, treatment plan did not address individual session frequency. Individual session progress notes documented 5/20/08 and 10/29/08.
Record # 8, treatment plan states individual sessions as needed, individual session progress note documented 11/3/08.
Record # 9, treatment plan does not address individual sessions. No Individual session progress notes documented.
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Plan of Correction
In a meeting on 03/25/2009, the Clinical Supervisor will educate counselors on the requirement that services provided reflect type and frequency of services documented on the individual treatment plan. Compliance will be monitored by the Clinical Supervisor on a monthly basis. The Outpatient Director will be responsible for oversight. |