INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of an individual training plan for employee # 1.
Employee # 1 was hired as the Project Director on 10/26/87. There was no documentation of an individual training plan for the current year, which was identified as 07/01/16- 06/30/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual training plans are done at the time of staff members performance reviews. On 3/15/17, the Vice President of Human Resources reached out to management regarding the importance of timely reviews. All outstanding reviews and training plans have since been submitted. The VP of HR will continue to track outstanding performance reviews. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form on 03/21/17, the facility failed to ensure that all staff persons received a minimum of 4 hours of TB/STD and other health related topics within the regulatory timeframe in personnel record #6.
Employee #6 was hired as a receptionist on 05/31/04. Employee #6 was due to complete the required TB/STD training no later than 05/31/06. There was no documentation in the employee file indicating that the employee received TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff in question are required to attend an upcoming offering of TB/STD on April 13 or find their own HIV/AIDs training externally, based on their needs. If the offending staff do not comply, they will face termination. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on 03/21/17 at approximately 2:15 P.M., the hot water temperature in the client and staff bathrooms upstairs and downstairs were measured at 125.7 degrees and 126 degrees, respectively.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The director of facilities maintenance turned down the water temps. Director or facilities will continue to monitor temps on a monthly basis. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, there was no documentation of an annual written individual performance evaluation in employee record # 1. Addtionally, there was no verification of professional credentials in employee record # 3.
Employee # 1 was hired as the Project Director on 10/26/87. There was no documentation of an annual employee evaluation since the last inspection.
Employee # 3 was hired as a counselor on 07/18/11 and was promoted to clinical supervisor on 01/16/17. There was no documentation of the employee's educational credentials in the employee 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
On 3/15/17, the Vice President of Human Resources reached out to management regarding the importance of timely reviews. All outstanding reviews have since been submitted. The VP of HR will continue to track outstanding performance reviews.
The missing credentials of the clinical supervisor were obtained on 3/22/17 and will continue to be monitored by the VP of HR.
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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
Based on a review of client records, client record #'s 1, 4, 5, 6, and 7 lacked documentation verifying written acknowledgement by clients that they had been notified of the client rights.
Client #1 was admitted on 04/18/16 and was an active client at the time of the inspection.
Client #4 was admitted on 02/19/16 and was discharged on 07/13/16.
Client #5 was admitted on 05/21/16 and was discharged on 10/12/16.
Client #6 was admitted on 04/06/16 and was discharged on 10/27/16.
Client #7 was admitted on 05/31/16 and was discharged on 12/05/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff responsible for documentation infractions will be required to attend a clinical documentation training refresher course on 4/20/17 that will focus on the importance of client rights acknowledgement. Director of Quality Assurance will continue to monitor documentation compliance
Client #1 signed a client rights acknowledgement on 3/22/17. |
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, client record #'s 1, 3, 4, 5, 6, and 7 were missing either the individual treatment and rehabilitation plan, the specification of the type and/or frequency of treatment and rehabilitation services on the comprehensive treatment plan, or documentation that the plan was developed with the client.
Client #1 was admitted on 04/18/16 and was an active client at the time of the inspection. The record did not contain an individual treatment and rehabilitation plan.
Client #3 was admitted on 11/22/16 and was an active client at the time of inspection. The record did not contain an individual treatment and rehabilitation plan.
Client #4 was admitted on 02/19/16 and was discharged on 07/13/16. The individual treatment and rehabilitation plan was signed and dated on 02/19/16 by the counselor, but the client did not sign and date the treatment plan, thus it appears that the plan was created without the input of the client. Progress notes did not indicate that the plan was developed with client input or why the plan was not signed at time of creation.
Client #5 was admitted on 05/21/16 and was discharged on 10/12/16. The record did not contain an individual treatment and rehabilitation plan.
Client #6 was admitted on 04/06/16 and was discharged on 10/27/16. The individual treatment and rehabilitation plan was signed and dated on 04/13/16 by the counselor, but was missing the client signature and date; thus, it appears that the plan was created without the input of the client. Progress notes did not indicate that the plan was developed with client input or why the plan was not signed at time of creation. Additionally, the plan was missing the type and frequency of services.
Client #7 was admitted on 05/31/16 and was discharged on 12/05/16. The individual treatment and rehabilitation plan was signed and dated on 05/31/16 by the counselor, but was missing the client signature and date; thus, it appears that the plan was created without the input of the client. Progress notes did not indicate that the plan was developed with client input or why the plan was not signed at time of creation. Additionally, the plan was missing the type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff responsible for documentation infractions will be required to attend a clinical documentation training refresher course on 4/20/17 that will focus on treatment planning. Director of Quality Assurance will continue to monitor documentation compliance.
Treatment plans will be completed for client 1 and 3 by 4/20/17. |
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, client record #'s 2, 4, 6, and 7 had treatment plan updates completed after the regulatory timeframe or were not completed at all.
Client #2 was admitted on 12/15/16 and was an active client at the time of the inspection. The individual treatment and rehabilitation plan was completed on 12/15/16 and an update was due no later than 02/15/17. However, there was no update completed at the time of the inspection.
Client #4 was admitted on 02/19/16 and was discharged on 07/13/16. The individual treatment and rehabilitation plan was completed on 02/19/16 and an update was due no later than 04/19/16. However, there was no update completed at the time of the inspection.
Client #6 was admitted on 04/06/16 and was discharged on 10/27/16. A treatment plan update was completed on 06/13/16 and the next update was due no later than 08/13/16. However, there was no update completed at the time of the inspection.
Client #7 was admitted on 05/31/16 and was discharged on 12/05/16. A treatment plan update was completed on 08/01/16 and the next update was due no later than 10/01/16. However, there was no update completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff responsible for documentation infractions will be required to attend a clinical documentation training refresher course on 4/20/17 that will focus on treatment planning. Director of Quality Assurance will continue to monitor documentation compliance.
Client #2 received a treatment plan update on 3/27/17. |
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 provide a complete client record in client records #'s 4, 5, 6, and 7.
Client #4 was admitted on 02/19/16 and was discharged on 07/13/16. The record did not contain documentation of case consultation notes or follow-up information as of the date of the inspection.
Client #5 was admitted on 05/21/16 and was discharged on 10/12/16. The record did not contain documentation of case consultation notes or follow-up information as of the date of the inspection.
Client #6 was admitted on 04/06/16 and was discharged on 10/27/16. The record did not contain documentation of case consultation notes as of the date of the inspection.
Client #7 was admitted on 05/31/16 and was discharged on 12/05/16. The record did not contain documentation of case consultation notes, follow-up information, discharge summary, or aftercare plan as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff responsible for documentation infractions will be required to attend a clinical documentation training refresher course on 4/20/17 that will focus on case consultations. Director of Quality Assurance will continue to monitor documentation compliance.
Office Managers, and administrative assistants will face disciplinary action if follow-up call compliance does not improve in the next 4 weeks. Director of Quality Assurance will continue to monitor.
The outstanding documentation was completed the week after the survey. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to ensure compliance with 55 PA. Code Part III, relating to medical assistance in client record # 7.
Client #7 was admitted on 05/31/16 and was discharged on 12/05/16 and was identified as a medical assistance client. The facility failed to obtain the physician signature on the client's comprehensive treatment plan, dated 05/31/16, and the treatment plan update, which was completed on 08/01/16.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Medical Director will sign treatment plans of all MA clients. Director of QA to monitor. |