INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 2018 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #4's training record.
Employee #4 was hired as a counselor on 08/24/2015 and was still in the position as of the date of the inspection. The facility's training year that was reviewed was from July 1, 2016 through June 30, 2017. Employee #4's training record only documented 6.5 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Human Resources Coordinator out reached Oxford Valley Management regarding the importance of staff training hour compliance on 4/4/2018. Training plan and requirements reviewed with this staff member during staff meeting on 4/5/2018. If the offending staff do not comply, they will face disciplinary act. Education Coordinator will continue to monitor training hours quarterly. |
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 7 client records, the facility failed to document treatment plan updates within the regulatory timeframe in 2 of 6 applicable client records.
Client #2 was admitted on 4/11/2017 and was still active at the time of the inspection. The comprehensive treatment plan was completed on 5/01/17 and the first update was due no later than 7/01/17; however, the update was not documented until 10/18/17. Additionally, the next update was due no later than 12/18/17; however, the update was not documented until 2/22/18.
Client #3 was admitted on 6/21/2017 and was still active at the time of the inspection. A treatment plan update was completed on 9/28/17 and the next update was due no later than 11/28/17; however, the update was not documented until 1/05/18. Additionally, the next update was due no later than 3/05/18; however, the update was not completed 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 importance of timely and quality treatment plans was shared with the offending clinical staff. The identified staff members are required to attend an upcoming offering of the Clinical Documentation Compliance 101 training on May 17th 2018, which will focus on treatment planning. The Director of Quality Improvement will be responsible for the ongoing monitoring of treatment plan compliance.
Client #2 was assessed on 4/11/2017 but did not engage in treatment until 4/26/2018. Clients treatment plan was discussed and signed on 5/1/2017. Treatment plans were not discussed in proper time frames due to client's lack of engagement. Client has since been transferred to a new counselor. A new treatment plan was discussed and signed with this client on 4/6/18.
Client #3 has since been discharged. |