INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 30, 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 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:
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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 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. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records on 03/22/17, the facility failed to ensure that personnel records contained documentation of an annual written individual performance evaluation in employee record # 1.
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.
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 the importance of timely reviews. All outstanding reviews have since been submitted. The VP of HR will continue to track outstanding performance reviews. |
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 client records, the facility failed obtain a completed informed and voluntary consent to release information form in 2 of 8 client records reviewed.
Client #1 was admitted on 08/25/2016 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 08/25/16 for the purpose of funding; however, there was no name or organization to whom the disclosure was to be made to.
Client #5 was admitted on 01/07/2016 and was discharged on 05/26/2016. A consent to release form was signed and dated on 01/07/16 for the purpose of funding; however, there was no name or organization to whom the disclosure was to be made to.
The findings were reviewed with facility staff during the licensing inspection.
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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 proper ROI. Director of Quality Assurance will continue to monitor documentation compliance.
The release in question for client #1 was amended on 3/31/17. |
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 psychosocial evaluations in 4 of 8 records reviewed.
Client #2 was admitted on 05/12/2016 and was still an active client at the time of the inspection.
Client #5 was admitted on 01/07/2016 and was discharged on 05/26/2016.
Client #6 was admitted on 03/13/2016 and was discharged on 10/26/2016.
Client #7 was admitted on 09/15/2016 and was discharged on 01/20/2017.
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 psychosocial assessments. Director of Quality Assurance will continue to monitor documentation compliance. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document preliminary treatment plans in 3 of 8 records reviewed.
Client #2 was admitted on 05/12/2016 and was still an active client at the time of the inspection.
Client #6 was admitted on 03/13/2016 and was discharged on 10/26/2016.
Client #7 was admitted on 09/15/2016 and was discharged on 01/20/2017.
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. |
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 3 of 8 records reviewed.
Client #5 was admitted on 01/07/2016 and was discharged on 05/26/2016. There was no documentation of follow-up information at the time of the inspection.
Client #6 was admitted on 03/13/2016 and was discharged on 10/26/2016. There was no documentation of follow-up information at the time of the inspection.
Client #7 was admitted on 09/15/2016 and was discharged on 01/20/2017. There was no documentation of follow-up information at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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.
Office Manager has completed follow-up calls in question as of 4/18/17. |