INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 15, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on February 15, 2024, the facility failed to ensure that exits from the nonresidential facility were unobstructed. The emergency exit door through the group room was obstructed, as it was locked.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been informed, Program Manager will ensure door remains unlocked during service hours. The Program Manager has posted a sign advising that the door must remain unlocked during service hours. The Program Manager will check the door daily to ensure it is unlocked. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information disclosed in eight out of eight records.
The facility failed to ensure release of information forms the clients had signed for their funding source contained the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Vice President and Compliance Specialist have reviewed and updated the language on the consent form in question to specify what information is to be released. Senior Vice President will ensure future revisions on the form include specific information to be released is more specific. Senior Vice President has sent a list of all active patients to the Program Manager, the Program Manager will ensure all active patients sign the new consent form when they arrive for their next appointment. Compliance Specialist will follow up weekly with Program Manager to obtain status update on the progress of getting new consents signed. The Program Manager will review all new patient consent forms to ensure accuracy. |
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
Based on a review of eight applicable client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in one record reviewed.
Client # 13 was admitted to the Outpatient level of care on October 5, 2023 and was active at the time of the inspection. A consent to release information form to an outside agency signed by the client on February 2, 2024, was missing the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent form for the patient in question has been corrected. During the most recent supervision the Program Manager re-educated staff of the necessary fields on consent forms. Program Manager will ensure compliance with proper consent completion during monthly chart audits. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include an aftercare plan, in one of one applicable client record reviewed.
Client # 11 was admitted on May 30, 2023 and was discharged on January 8, 2024. The client record did not contain documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During supervision the Program Manager re-educated staff on aftercare plan documentation requirements. During random chart audit review the Program Manger will ensure to review charts of discharge and active patients. The Program Manager will ensure compliance through monthly chart audits. |