INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16, 2023, 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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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 files, the facility failed to ensure that one applicable clinical supervisor who had not functioned for 2 years as a supervisor in the provision of clinical services completed a core curriculum in clinical supervision to qualify for the position.
Employee #3 was promoted to the position of clinical supervisor on February 21, 2022 and is current in that position. Employee #3 did not complete a core curriculum until October 21, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward the organization will ensure new supervisors will attend the appropriate training in the allotted time frame. Human Resources will ensure training is completed accordingly. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The organization was granted an extension on it's financial audit by the IRS, expected completion 6/30/2023. This extension was requested due to a change in staff. Proof of the IRS extension was provided at the time of the audit. If this should happen in the future the organization will request an extension from the department as well. The Controller and Finance consultant are responsible to oversee this process. |
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.
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Observations
Based on a review of 13 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in 11 records reviewed.
Client #2 was admitted to the partial hospitalization level of care on February 13, 2023 and was discharged on March 3, 2023. The record contained documentation that personally identifying information was released to the Department of Human Services on March 2, 2023, with no client signed consent to release information form signed by the client.
Client #3 was admitted to the partial hospitalization level of care on November 22, 2022 and was discharged on December 7, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on December 9, 2022, with no client signed consent to release information form signed by the client.
Client #4 was admitted to the partial hospitalization level of care on December 1, 2022 and was discharged on December 16, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on December 12, 2022, with no client signed consent to release information form signed by the client.
Client #5 was admitted to the partial hospitalization level of care on October 31, 2022 and was discharged on November 23, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on November 9, 2022, with no client signed consent to release information form signed by the client.
Client #6 was admitted to the partial hospitalization level of care on February 7, 2023 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on March 7, 2023, with no client signed consent to release information form signed by the client.
Client #7 was admitted to the outpatient level of care on September 26, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on October 14, 2022, with no client signed consent to release information form signed by the client.
Client #8 was admitted to the outpatient level of care on March 9, 2022 and was discharged on June 22, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on June 2, 2022, with no client signed consent to release information form signed by the client.
Client #9 was admitted to the outpatient level of care on December 28, 2022 and was discharged on January 16, 2023. The record contained documentation that personally identifying information was released to the Department of Human Services on January 11, 2023, with no client signed consent to release information form signed by the client.
Client #10 was admitted to the outpatient level of care on November 28, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on November 9, 2022, with no client signed consent to release information form signed by the client.
Client #11 was admitted to the outpatient level of care on August 31, 2022 and was discharged February 8, 2023. The record contained documentation that personally identifying information was released to the Department of Human Services on January 4, 2023, with no client signed consent to release information form signed by the client.
Client #12 was admitted to the outpatient level of care on June 9, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on March 7, 2023, with no client signed consent to release information form signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has added a consent for verification being run through DHS/Promise to avoid this from happening in the future. Staff will be sure to educate patients on this consent. Program Manager will ensure staff use the appropriate consent through random chart audits. In addition, a new consent has been created to ensure compliance of confidentiality. Of the clients in question, 1 is still active, Clients # 7 and 12 have discharged. Active Client to sign when presents to group. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one applicable record reviewed.
Client #8 was admitted to the outpatient level of care on March 9, 2022 and was discharged on June 22, 2022. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-educated on the requirement to send termination letters when an a patient has been involuntarily discharged from the program. Program Manager will monitor compliance through random chart audits. |
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 six client records and the facility ' s intake procedures, the facility failed to document a psychosocial evaluation by the seventh treatment session in two records reviewed.
Client #1 was admitted on September 8, 2022 and was discharged on September 23, 2022. The psychosocial evaluation was due to be completed by September 16, 2022, however, it was not completed prior to discharge.
Client #2 was admitted on February 13, 2023 and was discharged on March 3, 2023. The psychosocial evaluation was due to be completed by February 22, 2023, however, it was not completed until March 2, 2023.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Staff were reeducated on the time frames for the Psychosocial evaluation. Program Manager will perform random chart audits on a monthly basis to ensure compliance. |
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 a review of six records, the facility failed to ensure that counseling was provided to clients on a regular and scheduled basis, that included individual counseling, at least twice weekly in two records reviewed.
Client #1 was admitted to the partial hospitalization level of care on September 8, 2022 and was discharged on September 23, 2022. The record contained documentation of only one individual counseling session offered the treatment week of September 8, 2022 through September 14, 2022.
Client #5 was admitted to the partial hospitalization level of care on October 31, 2022 and was discharged on November 23, 2022. The record contained documentation of only one individual counseling session offered the treatment week of November 7, 2022 through November 13, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-educated on requirement to perform two individual session per week during PHP level of care. Program Manager will monitor compliance through random chart audits. The Director of Outpatient programing will complete weekly checks for all PHP clients to ensure Individual Sessions are held. |
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 a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in four of seven applicable client records reviewed.
Client #7 was admitted to the outpatient level of care on September 26, 2022 and was active at the time of the inspection. A treatment plan update was completed on November 14, 2022, and the next treatment plan update was due no later than January 14, 2023; however, no treatment plan updates were completed prior to the inspection.
Client #10 was admitted to the outpatient level of care on November 28, 2022 and was active at the time of the inspection. A treatment plan update was completed on December 8, 2022 and the next treatment plan update was due no later than February 8, 2023; however, the next treatment plan update was not completed until March 8, 2023.
Client #11 was admitted to the outpatient level of care on August 31, 2022 and was discharged February 8, 2023. A treatment plan update was completed on November 11, 2022 and the next treatment plan update was due no later than January 11, 2023; however, no treatment plan updates were completed prior to the client ' s discharge.
Client #12 was admitted to the outpatient level of care on June 9, 2022 and was active at the time of the inspection. A treatment plan update was completed on August 31, 2022 and the next treatment plan update was due no later than October 31, 2022; however, the next treatment plan update was not completed until January 12, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-educated on defined time frames for treatment plan completion. Client #7's Treatment Plan has been updated. Program Manager/Director of Outpatient will monitor compliance through random chart audits. |