INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 2008 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on April 18, 2008.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the policy and procedures, the facility did not document a complete staff development policy. The policy did not address who was responsible or the time frames for completion of the assessment of staff training needs and the overall training plan.
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Plan of Correction
5/5/2008 - The Project Director or his designee will revise the staff development program to include the required elements. A copy of the revised program will be forwarded to the Clinical Director/Facility Director for compliance monitoring. The new program will be in place for the 2008/2009 training year. |
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 and training records, the facility did not document the mandatory four hours of tuberculosis, sexually transmitted diseases and other health related topics in one of five records reviewed, #4.
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Plan of Correction
The Program Director will ensure that all staff meet the mandatory state training requirements for TB and STDs. Compliance will be monitored by the TQM Director. Employee #4 no longer works in our Allentown site. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel and training records, the facility failed to document that employee #1 earned the minimum number of 12 training hours for the July 2006 to June 2007 training year. Employee #1 had only 4 hours of training documented for the training year.
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Plan of Correction
5/5/2008 - Employee #1 will complete 12 training hours for training year 2008/2009. Compliance will be monitored by the TQM Director. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility did not document the utilization of alternative exit routes for fire drills conducted between July 2007 and February 2008. The fire drill records indicated that the same stairwell was used during each of the fire drills for the above time frame.
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Plan of Correction
The Program Manager will insure that alternative exit routes are utilized for monthly fire drills. Compliance will be monitored by the TQM Director. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the physical plant on March 21, 2008, the facility did not set off the fire alarm or smoke detection system within the building that the facility resides. The facility only set off a battery operated smoke detector within its own suite that was not interconnected with the rest of the building.
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Plan of Correction
This site is not permitted to conduct a fire drill for the entire building. We will apply for an exception.
5/5/2008 - The Program Director will apply for an exception to utilize an alternative method for announcing its monthly fire drills. Compliance will be monitored by the TQM Director. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the administrative records, the facility did not document the notification to the public of the project's 2006 to 2007 annual report.
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Plan of Correction
5/5/2008 - On 3/1/2008, the PR Director provided public notice of the availability of the 2006/2007 annual report. He will ensure that public notice is documented for subsequent years. Compliance will be monitored by the TQM Director. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the letters of agreement, the facility failed to document an agreement specific for 24-hour emergency psychiatric and medical coverage.
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Plan of Correction
5/5/2008 - The Program Director will obtain a referral agreement with a hospital which specifies the requirement for 24 hour emergency psychiatric and medical coverage. Compliance will be monitored by the TQM Director. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on an inspection of the sign-in list, the facility did not protect the confidentiality of client identities. The sign-in list required all clients coming in for treatment to put in their first and last names.
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Plan of Correction
In a meeting, the Program Director will instruct all staff to insure that patients use first names and last initials only on the sign-in list. The Program Director will follow up by checking the sign-in sheet daily for two weeks, and randomly thereafter. Compliance will be monitored by the TQM Director. |
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 did not document a notification of termination in one of one client record where the client was therapeutically discharged from treatment, #8.
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Plan of Correction
In a meeting, the Program Director will remind counselors that notification of termination is required for all patients who are therapeutically discharged from treatment. The Program Manager will follow up through the chart monitoring process. Compliance will be monitored by the
Director, TQM. |
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 did not document complete psychosocial evaluations in four of four client records reviewed, #1, 2, 3 and 4. The psychosocial evaluations did not include the counselor's assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment.
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Plan of Correction
In a meeting, the Program Director will remind counselors to include all required elements in the psychosocial evaluation. The Program Manager will follow up through the chart auditing process. Compliance will be monitored by the TQM Director. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility did not document the frequency of treatment services in three of four client records reviewed, #2, 3 and 4.
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Plan of Correction
In a meeting, the Program Director will remind staff of the requirement to include frequency of services on patient treatment plans. The Program Manager will follow up through the chart auditing process. Compliance will be monitored by the TQM Director. |
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 did not document complete treatment plan updates in three of four records reviewed, #3, 4 and 7. Treatment plan updates were missing an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in two records reviewed, #3 and 4. The treatment plan update was missing in one record reviewed, #7.
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Plan of Correction
5/5/2008 - In a meeting, the Program Director will remind counselors of the requirement to complete treatment plan updates every 60 days, and to include an assessment of the patient's progress in relationship to the stated goals of the comprehensive treatment plan. |
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.
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Observations
Based on a review of client records, the facility did not document complete group progress notes in four of four records reviewed, #1, 2, 3 and 4. The counselors wrote a weekly group note to summarize group counseling sessions that occurred throughout the course of one week. Two to three group sessions in each week were based on different topics and could not be summarized in a single weekly note.
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Plan of Correction
In a meeting, the Clinical Director will remind the Program Manager that Livengrin's policy regarding progress notes is to complete an individualized group note for each patient after each group session. In a meeting, the Program Manager will instruct counselors accordingly. The Program Manager will conduct random chart audits to insure compliance. Compliance will also be monitored by the TQM Director. |