D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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LIVENGRIN COUNSELING CENTER
31 SOUTH COMMERCE WAY<br>SUITE 300
BETHLEHEM, PA 18017

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Survey conducted on 03/02/2026

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on March 02, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:	Plan of Correction
709.28 (c) 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.
Observations Based on a review of client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information in one of the fourteen records reviewed. Client #4 was admitted on November 26, 2025, and still active at the time of the inspection. There was documentation that was disclosed to the funding source on January 22, 2026; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.This finding was reviewed with facility staff during the inspection process.	Plan of Correction During supervision on 3/20/2026, the Program Manager reeducated the team members on the information required on consent forms. The Program Manager will perform random chart audits throughout the year to ensure compliance. Consents for all active clients have been updated.
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.
Observations Based on a review of seven partial hospitalization client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed within 24 hours after therapy sessions, in seven of seven records reviewed. Client #8 was admitted on October 24, 2025 and stepped down to the outpatient level of care on December 01, 2025. The record contained progress notes for individual sessions occurring on October 24, 2025, November 05, 2025, November 17, 2025 and November 24, 2025, that were not completed until October 28, 2025, December 01, 2025, November 28, 2025, and November 28, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on November 17, 2025 and November 20, 2025, that were not completed until November 25, 2025 and November 25, 2025, respectively. Client #9 was admitted on September 22, 2025 and stepped down to the outpatient level of care on November 03, 2025. The record contained progress notes for individual sessions occurring on October 14, 2025, and October 20, 2025, that were not completed until October 16, 2025 and October 29, 2025, respectively. Additionally, the record contained a progress note for a group session occurring on September 24, 2025, that was not completed until September 28, 2025. Client #10 was admitted on November 05, 2025 and discharged on December 15, 2025. The record contained progress notes for individual sessions occurring on November 05, 2025 and November 17, 2025 that were not completed until November 11, 2025 and February 28, 2026, respectively. Additionally, the record contained a progress note for a group session occurring on November 17, 2025, and was not completed until February 28, 2026. Client #11 was admitted on February 16, 2026, and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on February 16, 2026 and February 25, 2026, that were not completed until February 18, 2026, and February 27, 2026, respectively. Additionally, the record contained a progress note for a group session occurring on February 25, 2026, that was not completed until February 27, 2026.Client #12 was admitted on December 16, 2025, and was still active at the time of the inspection. The record contained progress notes for individual sessions on January 15, 2026, and January 22, 2026, and both were not completed until February 03, 2026.Client #13 was admitted on January 07, 2026, and stepped down to the outpatient level of care on February 23, 2026. The record contained progress notes for individual sessions occurring January 15, 2026, January 20, 2026, January 27, 2026, January 29, 2026, February 02, 2026, February 06, 2026, February 09, 2026, and February 17, 2026, that were not completed until January 19, 2026, January 23, 2026, February 04, 2026, February 24, 2026, February 04, 2026, February 08, 2026, February 27, 2026, and February 20, 2026, respectively. Additionally, the record contained progress notes for group sessions occurring on February 17, 2026, and February 25, 2026, that were not completed until February 20, 2026, and February 27, 2026, respectively. Client #14 was admitted on December 22, 2025, and stepped down to the outpatient level of care on February 18, 2026. The record contained progress notes for individual sessions occurring on December 29, 2025, December 31, 2025, January 06, 2026, January 07, 2026, January 09, 2026, January 12, 2026, January 19, 2026, January 30, 2026, February 02, 2026, February 05, 2026, February 09, 2026, and February 13, 2026, that were not completed until January 02, 2026, January 02, 2026, January 09, 2026, January 09, 2026, January 16, 2026, January 16, 2026, January 27, 2026, February 02, 2026, February 04, 2026, February 12, 2026, February 12, 2026, and February 17, 2026, respectively. Additionally, the record contained a progress note for a group session occurring on February 24, 2026, that was not completed until February 26, 2026. These findings were reviewed with facility staff during the licensing process.	Plan of Correction During supervision on 3/20/2026, 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.
709.83(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.
Observations Based on a review of seven partial hospitalization 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 follow up information, per the facility's policy to be completed in 30 days in one out of one applicable record reviewed. Client #10 was admitted on November 05, 2025 and discharged on December 15, 2025. The follow up was due to be completed by January 15, 2026; however, one was not documented until February 03, 2026. This finding was reviewed with facility staff during the licensing process.	Plan of Correction During supervision on 3/20/2026, the team members were re-educated on the proper documentation protocols. The Program Manager and Office Manager will work in tandem 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.
709.93(a)(5) 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: (5) Progress notes.
Observations Based on a review of seven outpatient client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed within 24 hours after therapy sessions, in six of seven records reviewed. Client #1 was admitted on June 19, 2025 and was discharged on September 30, 2025. The record contained a progress note for a group session occurring on July 03, 2025, that was not completed until July 7, 2025. Client #2 was admitted on June 24, 2025 and still active at the time of the inspection. The record contained progress notes for individual sessions occurring on July 01, 2025, July 24, 2025, August 11, 2025, August 28, 2025, January 05, 2026, January 19, 2026, February 02,2026, and February 16, 2026, that were not completed until July 03, 2025, July 28, 2025, August 14, 2025, September 02, 2025, January 12, 2026, January 25, 2026, February 06, 2026, and February 20, 2026, respectively. .Client #3 was admitted on May 15, 2025 and still active at the time of the inspection. The record contained progress notes for individual sessions occurring on August 13, 2025 and November 06, 2025 that were not completed until August 15, 2025 and November 12, 2025, respectively. Additionally, the record contained a progress note for a group session occurring on September 24, 2025 and was not completed until September 28, 2025. Client #4 was admitted on November 26, 2025 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on November 26, 2025 and was not completed until December 09, 2025.Client #6 was admitted on November 03, 2025 and was still active at the time of the inspection. The record contained a progress note for a group session occurring on December 29, 2025 and was not completed until January 06, 2026. Client #7 was admitted on August 11, 2025 and was discharged on November 13, 2025. The record contained progress notes for individual sessions occurring on September 09, 2025 and November 11, 2025, that were not completed until September 11, 2025 and November 13, 2025, respectively. These findings were reviewed with facility staff during the licensing process.	Plan of Correction During supervision on 3/20/2026, 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.
Observations Based on a review of seven outpatient 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 follow up information, per the facility's policy to be completed in 30 days, in three out of three applicable records reviewed. Client #1 was admitted on June 19, 2025 and discharged on September 30, 2025. The follow up was due to be completed by October 30, 2025; however, the client record did not contain documentation of a follow up being completed.Client #5 was admitted on September 10, 2025 and discharged on January 19, 2026. The follow up was due to be completed by February 19, 2026; however, the client record did not contain documentation of a follow up being completed. Client #7 was admitted on August 11, 2025 and discharged on November 13, 2025. The follow up was due to be completed by December 13, 2025; however, one was not documented until December 30, 2025. These findings were reviewed with facility staff during the licensing process.	Plan of Correction During supervision on 3/20/2026, the team members were re-educated on the proper documentation protocols. The Program Manager and Office Manager will work in tandem 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.