INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11, 2015 by staff from the Division of Drug and Alcohol Program Licensure. 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(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 staff development records, the facility failed to provide documentation that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD and other health related topics training using a Department approved curriculum in one of three personnel records.
The findings include:
Three personnel and staff development records requiring documentation of HIV/AIDS and TB/STD training were reviewed on February 2-3, 205. The facility failed to provide documentation that Employee #1 received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD and other health related topics training.
Employee # 1 was hired on July 18, 2013. HIV/AIDS and TB/STD training was due to be completed no later than July 18, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A list of all staff out of compliance with mandatory trainings will be compiled by the 04/01/2015. Staff who are out of compliance will be required to attend upcoming HIV/AIDS and TB/STD trainings in our area in April and May 2015. This will be monitored and followed up on by the head of the Training Department. The implementation of electronic monitoring of training attendance by ADP will ensure that all staff maintain training compliance. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel and staff development records, the facility failed to ensure that a sufficient number of staff persons were trained in CPR and first aid so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
Three personnel and staff development records were reviewed on February 2-3, 2015. The facility is open 8:00 AM to 4:30 PM ~ Monday thru Friday. The facility failed to ensure that a sufficient number of staff persons were trained in CPR and first aid as employee #2 was the only staff person to receive CPR and first aid training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A list of all staff out of compliance with mandatory trainings will be compiled by 04/01/2015. A CPR training is being held in May 2015 at Livengrin Foundation which all staff who are out of compliance will be required to attend. This will be monitored by the head of the Training Department. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log, the facility failed to prepare alternate exit routes and conduct fire drills on different staffing shifts.
The findings include:
On February 11, 2015, the facility's fire drill log was reviewed covering the period of February 2014 through January 2015. The facility failed to prepare alternate exit routes and conduct fire drills on different staffing shifts.
The facility documented on each monthly fire drill log, "back exit" and 8AM - 2PM shift.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The importance of utilizing differing exits and shifts during fire drills will be reiterated to all staff who conduct fire drills. Fire drill logs will be kept on a shared drive so that they may be reviewed by the Quality Assurance Manager on a monthly basis to ensure that this deficiency does not recur. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document an annual written staff performance evaluation which shall be reviewed and signed by the employee in one of three personnel records.
The findings include:
Three personnel records requiring documentation of an annual written staff performance evaluation were reviewed on February 2-3, 2015. The facility did not document an annual performance evaluation in Employee #1 personnel record.
Employee # 1 was hired on July 18, 2013. The annual work performance evaluation for 2014 was due for the time period July 18, 2013 to July 18, 2014. The facility failed to document an annual work performance evaluation as of the date of the licensing inspection.
These finding were reviewed with facility staff during the licensing process,
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Plan of Correction
A new electronic Human Resources system, ADP, was put in place 01/01/2015. This system will allow for precise, electronic tracking and follow up of mandated trainings, training plans, and performance reviews for staff. Staff who are missing key documentation such as individual training plans, annual performance reviews and mandatory trainings will be flagged and followed up on appropriately until compliance is met. The head of the Training Department is responsible for implementation and monitoring. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to comply with the limitations imposed by 4 Pa. Code 255.5 for an informed and voluntary consent for the disclosure of information in two of four records reviewed.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Four client records requiring documentation of informed and voluntary consents were reviewed on February 4, 2015. The facility failed to obtain an informed and voluntary consent to release client information in client record # 1 and 2.
Client # 1 was admitted to the program on August 26, 2014. The facility documented the release of information to a governmental entity which exceeded the limitations imposed at 4 Pa. Code 255.5. On August 21, 2014 consent to release was obtained allowing for the release of the client's dates of treatment.
Client # 2 was admitted to the program on December 15, 2014. The facility documented the release of information to a governmental entity which exceeded the limitations imposed at 4 Pa. Code 255.5. On November 24, 2014 consent to release was obtained allowing for the release of the client's discharge summary.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new release will be created in the EMR system with the 5 perimeters listed in 255.5 by Quality Assurance Manager by 04/05/2015. Confidentiality will be reviewed in a staff training and work groups by clinical supervisors. The appropriate use of releases will be monitored on a daily basis by Medical Records staff. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history in two of four records reviewed.
The findings include:
Four client records requiring documentation of the client's medical history were reviewed on February 3, 2015. The facility failed to document a medical history in client records, # 1 and 2.
Client # 1 was admitted to the program on August 26, 2014. The facility failed to document a medical history in client record # 1 as of the date of the licensing inspections.
Client # 2 was admitted to the program on December 15, 2014. The facility failed to document a medical history in client record # 2 as of the date of the licensing inspections.
The findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The current medical history used in outpatient is a paper form which needs to be faxed to the Medical Director for review and then faxed back to the office where the patient is being seen. This system is time consuming and fallible. Ultimately the goal is for the form to be incorporated into the EMR system. In the interim, the system will be tightened by eliminating the need to have the form faxed back to the office the patient is being seen. The Medical Records Department will be responsible for ensuring all medical forms are uploading into the patient chart in a timely manner. |
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 failed to document treatment and rehabilitation plan updates at least every 60 days in two of four records reviewed.
The findings include:
Four client records were reviewed on February 3, 2015. The facility failed to document treatment plan updates every 60 days in two client records, # 1 and 3.
Client # 1 was admitted to the program on August 26, 2014. The facility documented two treatment plans updates, dated November 6, 2014 and January 29, 2015. The facility failed to document treatment plan updates at least every 60 days as of the date of the licensing inspections.
Client # 3 was admitted to the program on June 4, 2014. The facility documented two treatment plans updates, dated July 31, 2014 and January 19, 2015. The facility failed to document treatment plan updates at least every 60 days as of the date of the licensing inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A revision to our internal auditing procedure is set to roll out by 09/01/2015. With this update, Sigmund, Livengrin's EMR system, will conduct automated audits rather than manual audits conducted by a staff member. This will ensure accuracy and promote a culture of compliance. Timely treatment plan updates will be a quality measure implemented within the new system. In the interim, clinical supervisors and members of the Quality Improvement team randomly audit charts on a weekly basis for the presence of all required documentation. Additionally, every active chart is audited weekly by a Quality Improvement team member to ensure that all documentation is complete. The current and projected audit systems are being overseen by the Quality Assurance Manager. |