INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 24, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the person, agency or organization to whom disclosure would be made to on informed and voluntary consent to release information forms in two of fourteen client records reviewed. Client # 6 was admitted to the partial hospitalization activity on December 3, 2019 and was discharged on December 19, 2019. A release of information form with the purpose of funding was signed and dated by the client and witness on November 20, 2019. Client #13 was admitted to the outpatient activity on December 20, 2019 and was discharged on February 3, 2020. A release of information form with the purpose of funding was signed and dated by the client and witness on November 20, 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff members have all been assigned 42 CFR training through Relias, Livengrin's learning management system. All managers will review consent requirements during staff meetings. Consent requirements fact sheets aligned with PA code 255.5 and the required elements of consent have been distributed to managers, supervisors and directors. Consents will be reviewed by Livengrin Admissions staff, Clinical Counseling Staff and Office Managers at admission and each subsequent level of care to determine necessary consents for all stakeholders have been obtained. The Complaince team will complete random chart audits of the work by managers, supervisors and directors.
All consents for active clients have been reviewed and updated. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on consent to release information forms in two of fourteen client records reviewed. Client # 2 was admitted to the partial hospitalization activity on October 28, 2018 and was discharged on November 8, 2019. The record contained a consent to release of information form to a parole officer that was missing the purpose of the disclosure.Client #11 was admitted to the outpatient activity on June 30, 2020 and was still active at the time of the inspection. A release of information form to a government agency was signed and dated by the client and witness on June 30, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After further review the facility identified that all consent forms for client 2 did indicate a purpose of disclosure. Staff members have all been assigned 42 CFR training through Relias, Livengrin's learning management system. All managers will review consent requirements during staff meetings. Consent requirements fact sheets aligned with PA code 255.5 and the required elements of consent have been distributed to managers, supervisors and directors. Consents will be reviewed by Livengrin Admissions staff, Clinical Counseling Staff and Office Managers at admission and each subsequent level of care to determine necessary consents for all stakeholders have been obtained. The Complaince team will complete random chart audits of the work by managers, supervisors and directors.
All consents for active clients have been reviewed and updated. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to ensure that consent to release information forms contained the dated signature of the client in one of fourteen client records reviewed. Client #12 was admitted to the outpatient activity on October 9, 2019 and was discharged on November 12, 2019. A release of information form to a pharmacy was signed dated by the witness on October 9, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff members have all been assigned 42 CFR training through Relias, Livengrin's learning management system. All managers will review consent requirements during staff meetings. Consent requirements fact sheets aligned with PA code 255.5 and the required elements of consent have been distributed to managers, supervisors and directors. Consents will be reviewed by Livengrin Admissions staff, Clinical Counseling Staff and Office Managers at admission and each subsequent level of care to determine necessary consents for all stakeholders have been obtained. The Compliance team will complete random chart audits of the work by managers, supervisors and directors.
All consents for active clients have been reviewed and updated. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to ensure the documentation of written acknowledgement by clients that they have been notified that when they are receiving care or treatment under section 7 of the act (71 P. S. 1690.107), they shall retain all their civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in two of fourteen client records reviewed.Client # 2 was admitted to the partial hospitalization activity on October 28, 2019 and was discharged on November 8, 2019. Client # 4 was admitted to the partial hospitalization activity on November 15, 2019 and was discharged on December 4, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been assigned consents/forms/mandatory notifications training via Relias to review requirements for a valid consents/forms/mandatory notification. Additionally, a list of all required signed consents/forms/mandatory notifications has been distributed to the Program Managers and Director of Outpatient Services. The Program Manager and Director of Outpatient Services are responsible for auditing patient charts for proper completion of consents/forms/mandatory notifications.
The appropriate client rights attestation has been signed and updated in the active patient's chart. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to ensure the documentation of written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in two of fourteen client records reviewed.Client # 2 was admitted to the partial hospitalization activity on October 28, 2019 and was discharged on November 8, 2019. Client # 4 was admitted to the partial hospitalization activity on November 15, 2019 and was discharged on December 4, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been assigned consents/forms/mandatory notifications training via Relias to review requirements for a valid consents/forms/mandatory notification. Additionally, a list of all required signed consents/forms/mandatory notifications has been distributed to the Program Managers and Director of Outpatient Services. The Program Manager and Director of Outpatient Services are responsible for auditing patient charts for proper completion of consents/forms/mandatory notifications.
The appropriate client rights attestation has been signed and updated in the active patient's chart. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical 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 in the record.
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Observations
The facility failed to ensure the documentation of written acknowledgement by clients that they have been notified that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if that director determines that the information may be detrimental if presented to the client and the reasons for the removal of such sections shall be documented in the record in two of fourteen client records reviewed.Client # 2 was admitted to the partial hospitalization activity on October 28, 2019 and was discharged on November 8, 2019. Client # 4 was admitted to the partial hospitalization activity on November 15, 2019 and was discharged on December 4, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been assigned consents/forms/mandatory notifications training via Relias to review requirements for a valid consents/forms/mandatory notification. Additionally, a list of all required signed consents/forms/mandatory notifications has been distributed to the Program Managers and Director of Outpatient Services. The Program Manager and Director of Outpatient Services are responsible for auditing patient charts for proper completion of consents/forms/mandatory notifications.
The appropriate client rights attestation has been signed and updated in the active patient's chart. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to ensure the documentation of written acknowledgement by clients that they have been notified that all clients have the right to appeal, to the director, a decision limiting access to their records in two of fourteen client records reviewed.Client #2 was admitted to the partial hospitalization activity on October 28, 2019 and was discharged on November 8, 2019. Client # 4 was admitted to the partial hospitalization activity on November 15, 2019 and was discharged on December 4, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been assigned consents/forms/mandatory notifications training via Relias to review requirements for a valid consents/forms/mandatory notification. Additionally, a list of all required signed consents/forms/mandatory notifications has been distributed to the Program Managers and Director of Outpatient Services. The Program Manager and Director of Outpatient Services are responsible for auditing patient charts for proper completion of consents/forms/mandatory notifications.
The appropriate client rights attestation has been signed and updated in the active patient's chart. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The facility failed to ensure the documentation of written acknowledgement by clients that they have been notified that all clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in two of fourteen client records reviewed.Client #2 was admitted to the partial hospitalization activity on October 28, 2019 and was discharged on November 8, 2019. Client # 4 was admitted to the partial hospitalization activity on November 15, 2019 and was discharged on December 4, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been assigned consents/forms/mandatory notifications training via Relias to review requirements for a valid consents/forms/mandatory notification. Additionally, a list of all required signed consents/forms/mandatory notifications has been distributed to the Program Managers and Director of Outpatient Services. The Program Manager and Director of Outpatient Services are responsible for auditing patient charts for proper completion of consents/forms/mandatory notifications.
The appropriate client rights attestation has been signed and updated in the active patient's chart. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
The facility failed to ensure the documentation of written acknowledgement by clients that they have been notified that all clients have the right to submit rebuttal data or memoranda to their own records in two of fourteen client records reviewed.Client #2 was admitted to the partial hospitalization activity on October 28, 2019 and was discharged on November 8, 2019. Client # 4 was admitted to the partial hospitalization activity on November 15, 2019 and was discharged on December 4, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been assigned consents/forms/mandatory notifications training via Relias to review requirements for a valid consents/forms/mandatory notification. Additionally, a list of all required signed consents/forms/mandatory notifications has been distributed to the Program Managers and Director of Outpatient Services. The Program Manager and Director of Outpatient Services are responsible for auditing patient charts for proper completion of consents/forms/mandatory notifications.
The appropriate client rights attestation has been signed and updated in the active patient's chart. |
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
The facility failed to maintain a complete client record on an individual, which is to include follow-up information, in five of seven applicable client records. Client #1 was admitted into the partial hospitalization level of care on June 11, 2019 and was discharged on July 1, 2019. There was no follow-up information in the client record at the time of the inspection. Client #2 was admitted the partial hospitalization level of care on October 28, 2019 and was discharged on November 8, 2019. There was no follow-up information in the client record at the time of the inspection. Client #3 was admitted the partial hospitalization level of care on October 17, 2019 and was discharged on October 28, 2019. There was no follow-up information in the client record at the time of the inspection. Client #5 was admitted the partial hospitalization level of care on September 10, 2019 and was discharged on September 26, 2019. There was no follow-up information in the client record at the time of the inspection. Client #7 was admitted the partial hospitalization level of care on March 28, 2019 and was discharged on April 4, 2019. There was no follow-up information in the client record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After additional review of client records it was noted that follow up was documented for the clients 1, 3, 5, & 7. The Program Manager and Director of Outpatient Services have reviewed with staff the required follow up documentation. The Program Manager and the Director of Outpatient Services will be performing random chart audits. Staff the are found to have continue occurrences may be subject to corrective action. |
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
The facility failed to ensure that all treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of four applicable client records. Client #9 was admitted to the outpatient activity November 9, 2018 and was still active at the time of the inspection. A treatment plan update was completed on July 8, 2019 with the next update due no later than September 8, 2019; however, the update was completed on October 24, 2019. Another treatment plan update was completed on January 20, 2020 with the next update due no later than March 20, 2020; however, the update was completed on May 7, 2020. Additionally, another treatment plan update was completed on June 16, 2020 with the next update due no later than August 16, 2020; however, the update was completed on September 20, 2019. Client #10 was admitted to the outpatient activity on May 8, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on May 21, 2020 with an update due no later than July 21, 2010; however, the update was completed on August 26, 2020.Client #14 was admitted to the outpatient activity on September 14, 2019 and was discharged on April 2, 2020. The comprehensive treatment plan was completed on October 23, 2019 with an update due no later than December 23, 2019; however, the update was completed on March 11, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After additional review of client 14 chart it was noted that all treatment plans were updated at the appropriate intervals. Program Manager reviewed the time frames for treatment plans with staff during weekly staff meeting. Protocol discussed with clinicians to review treatment plan updates 10 days prior to expiration and complete early as necessary to ensure compliance with regulations. Program Managers are pulling embedded Aura Reports: Patients with Expiring Treatment Plans and Patients without existing treatment plans weekly to address compliance of treatment planning and treatment plan updating. The site manager will continue to monitor chart compliance monthly using a random sample. The sample size will be increased from 5 charts per month to 10 charts per month. Any clinician staff failing to maintain chart compliance may be subject to corrective action. |
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.
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Observations
The facility failed to maintain a complete client record on an individual, which is to include follow-up information, in four of four applicable client records. Client #8 was admitted the outpatient activity on December 13, 2019 and was discharged on January 10, 2020. There was no follow-up information in the client record at the time of the inspection. Client #12 was admitted the outpatient activity on October 9, 2019 and was discharged on November 12, 2019. There was no follow-up information in the client record at the time of the inspection. Client #13 was admitted the outpatient activity on December 20, 2019 and was discharged on February 3, 2020. There was no follow-up information in the client record at the time of the inspection. Client #14 was admitted to the outpatient activity on September 4, 2019 and was discharged on April 2, 2020. There was no follow-up information in the client record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Outpatient Program Managers will review the clinicians documentation weekly. Non-compliance will be addressed as part of weekly supervision with all clinicians. Staff members with continued non-compliance with documentation requirements may be subject to corrective action by their immediate supervisor. Site will continue to conduct chart audits to ensure staff adherence to all documentation requirements. |