INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2022 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in four of ten records reviewed.
The facility policy and procedure manual stated that the comprehensive treatment plan is to be completed no later than the 7th treatment day for the partial hospitalization activity and no later than the 7th counseling session for the outpatient program.
Client # 6 was admitted to the partial hospitalization activity April 29, 2021 and was discharged on June 1, 2021. The comprehensive treatment plan was due to be completed no later than May 5, 2021; however, the treatment plan was not completed until May 14, 2021.
Client # 10 was admitted to the outpatient activity on November 15, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than December 2, 2021; however, the treatment plan was not completed until January 25, 2021.
Client # 11 was admitted to the outpatient activity on November 18, 2021 and was discharged on March 7, 2021. The comprehensive treatment plan was due to be completed no later than December 2, 2021; however, the treatment plan was not completed until December 23, 2021.
Client # 14 was admitted to the outpatient activity on August 19, 2021 and was discharged on January 9, 2022. The comprehensive treatment plan was due to be completed no later than September 7, 2021; however, the treatment plan was not completed until September 17, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The appropriate staff were reeducated during clinical supervision the proper completion intervals of treatment plan completion. The Program Manager will perform random chart audit to ensure proper compliance. |
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 client records, the facility failed to document the purpose of the disclosure on release of information forms in two of fourteen client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on April 29, 2021 and was discharged on June 1, 2021. A release of information form to another treatment provider was signed and dated by the client and witness on May 13, 2021; however, the form did not document the purpose of the disclosure.
Client # 12 was admitted to the outpatient activity on June 1, 2021 and was discharged on December 16, 2021. A release of information form to another treatment provider was signed and dated by the client and witness on May 13, 2021; however, the form did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The employees in question have been reeduated on the proper consent form completion. The Program Manager will perform random chart aduits to ensure continued compliance. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's March 2021 through February 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following the facility receiving notification of the off-site death of a client on December 16, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been reeducated on the allowed time frames of incident reports and reportable events. Department heads will be responsible for ensuring the appropriate reports are submitted by their staff in a timely manner to the compliance department. The VP of Compliance will randomly review reported incidents to ensure continued compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to assure that clients admitted to the partial hospitalization program received individual counseling services at least twice a week in three of six applicable client records.
Client # 5 was admitted to the partial hospitalization activity on December 22, 2021 and was discharged on January 10, 2022. The record of service and progress notes indicated that there was only 1 individual counseling session during the week of January 2, 2022 through January 8, 2022.
Client # 6 was admitted to the partial hospitalization activity on April 29, 2021 and was discharged on June 1, 2021. The record of service and progress notes indicated that there were no individual counseling sessions during the weeks of May 2, 2021 through May 8, 2021 and May 16, 2021 through May 22, 2021. Additionally, there was only 1 individual counseling session during the week of May 23, 2021 through May 29, 2021.
Client # 7 was admitted to the partial hospitalization activity on June 2, 2021 and was discharged on July 12, 2021. The record of service and progress notes indicated that there were no individual counseling sessions during the weeks of June 20, 2021 through June 26, 2021 and July 4, 2021 through July 10, 2021. Additionally, there was only 1 individual counseling session during the weeks of June 6, 2021 through June 12, 2021, June 13, 2021 through June 19, 2021 and June 27, 2021 through July 3, 2021.
This is a repeat citation from the March 11, 2021, March 13, 2020 and March 8, 2019 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The appropriate staff were reeducated during clinical supervision the requirements for patients in partial level of care and the proper completion intervals of treatment plans. The Program Manager will perform random chart audit to ensure proper compliance. Counselors will be tracking individual sessions using a compliance tracking check list and manager will sign off on tracking sheet by the end of the week to ensure the clients in PHP are scheduled for the appropriate amount of sessions per week. |
709.93(a)(8) 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:
(8) Case consultation notes.
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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 case consultation notes, in two of six applicable client records reviewed.
Client # 10 was admitted to the outpatient activity on November 15, 2021 and was still active at the time of inspection. The record did not document case consultation notes at the time of the inspection.
Client # 12 was admitted to the outpatient activity on June 1, 2021 and was discharged on December 16, 2021. The record did not document case consultation notes 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 appropriate staff were reeducated during clinical supervision the requirements and time intervals for case consulation documentation. Both clients have been discharged from treatment, documentation was unable to be adjusted. The Program Manager will perform random chart audit to ensure proper compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to assure that clients, admitted to the partial hospitalization activity, received individual counseling services at least twice a week were submitted and approved by the Department for the March 11, 2021, March 13, 2020, and March 8, 2019, annual licensing inspections. Failing to assure that clients admitted to the partial hospitalization activity received individual counseling services at least twice a week were again found to be a deficiency in the March 10, 2022, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The appropriate staff were reeducated during clinical supervision the requirements for patients in partial level of care and the proper completion intervals of treatment plans. The Program Manager and Director of Outpatient Services will perform random chart audit to ensure proper compliance. Counselors will be tracking individual sessions using a compliance tracking check list and program manager will sign off on tracking sheet by the end of the week to ensure the clients in PHP are scheduled for the appropriate amount of sessions per week. |