INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 7, 2019 to March 8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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.
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
The facility failed to provide documentation that the current training year's individual training plan was appropriate to the employee's skill level in two of five personnel records reviewed.
Employee # 4 was hired as a counselor on June 22, 2015. The individual training plan, signed by the employee and supervisor on September 10, 2018, failed to document any trainings.
Employee # 5 was hired as a counselor on September 28, 2016. The individual training plan, signed by the employee and supervisor on October 18, 2018, failed to document any trainings.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A new VP of Human Resources was appointed in January of 2019 and is overseeing the overall improvement of the staff development program, which includes reviewing training plans for substance upon submission from staff/managers and holding managers accountable to submit training plans on time.
The Human Resources Generalist will pull all employee files who would be responsible for conducting an Annual Performance Evaluation(managers, directors, VP) job descriptions and add Annual Performance Evaluations as function of their job. The timely completion of Annual Performance Evaluations will become part of the employee (manager, director, VP) Performance Evaluations. The Human Resources Generalist will add a calendar invitation to the manager/director/VP internal calendar 3 months prior to the due date to ensure timely submissions for 90 day and Performance Evaluations. The Human Resources Generalist will review every submission of 90 day Evaluations and Performance Evaluations for 100% accuracy.
|
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.
|
Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 1 of 14 client records.
Client # 6 was admitted to the partial hospitalization level of care on December 4, 2018 and was discharged on December 26, 2018. There was documentation of a family counseling session on December 14, 2018 and telephone contact with a family member on December 17, 2018; however, there were no consent to release information forms on file prior to the disclosure of information. Additionally, there was documentation of the facility billing the funding source; however, there was no consent form on file as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality Improvement has scheduled a Confidentiality & Consent refresher with the appropriate staff on April 1, 2019.
Additionally, the Director of Quality Improvement has add consent review to monthly compliance audits.
|
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
The facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on a consent to release information form in 3 of 14 client records.
Client # 3 was admitted to the partial hospitalization level of care on February 13, 2019 and was still active at the time of the inspection. There was a consent to release information form on a significant other/family member template, signed and dated by the witness on February 7, 2019; however, the consent form did not include the specific name of the family member.
Client # 7 was admitted to the partial hospitalization level of care on January 23, 2019 and was discharged on February 14, 2019. There was a consent to release information form on the PCP template, signed and dated by the client on January 22, 2019; however, the consent form did not include the specific name of primary care physician.
Client # 14 was admitted to the outpatient level of care on May 15, 2018 and was discharged on February 19, 2019. There was a consent to release information form on the managed care template, signed by the client; however, the consent form did not include the specific name of the managed care organization.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality Improvement has scheduled a Confidentiality & Consent refresher with the appropriate staff on April 1, 2019.
Additionally, the Director of Quality Improvement has add consent review to monthly compliance audits.
All active client charts had their consents were updated by March 25th. |
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.
|
Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 1 of 14 client records.
Client # 4 was admitted to the partial hospitalization level of care on September 6, 2018 and was discharged on September 20, 2018. The record contained a consent to release information form to a government agency, signed and dated by the client on September 5, 2018, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of all treatment plans, all progress notes, all evaluations and all drug screens.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality Improvement has scheduled a Confidentiality & Consent refresher with the appropriate staff on April 1, 2019. Additionally, the Director of Quality Improvement will explore reporting requirements with PHMP by 3/22/2019. |
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.
|
Observations
The facility failed to document the purpose of disclosure on the consent form in 2 of 14 client records.
Client # 5 was admitted to the partial hospitalization level of care on November 26, 2018 and was discharged on December 10, 2018. There was a consent to a probation office, signed and dated by the client on November 20, 2018; however, the consent to release form did not include the purpose for disclosure.
Client # 7 was admitted to the partial hospitalization level of care on January 23, 2019 and was discharged on February 14, 2018. There was a consent to another provider, signed and dated by the witness on January 22, 2019; however, the consent to release form did not include the purpose for disclosure.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality Improvement has scheduled a Confidentiality & Consent refresher with the appropriate staff on April 1, 2019.
Additionally, the Director of Quality Improvement has add consent review to monthly compliance audits.
|
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
The facility failed to document the dated signature of a client on a consent to release information form in 3 of 14 client records.
Client # 3 was admitted to the partial hospitalization level of care on February 13, 2019 and was still active at the time of the inspection. There was a consent to release information form on the significant other/family member template, signed and dated by the witness on February 7, 2019; however, the consent form did not include the dated client signature.
Client # 7 was admitted to the partial hospitalization level of care on January 23, 2019 and was discharged on February 14, 2018. There was a consent to another provider, signed and dated by the witness on January 22, 2019; however, the consent to release form did not include the dated client signature.
Client # 14 was admitted to the outpatient level of care on May 15, 2018 and was discharged on February 19, 2019. There was a consent to release information form on the managed care template, signed by the client; however, the consent form did not include a date with the client signature.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality Improvement has scheduled a Confidentiality & Consent refresher with the appropriate staff on April 1, 2019.
Additionally, the Director of Quality Improvement has add consent review to monthly compliance audits.
All active client charts had consents updated by March 25th. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
|
Observations
The facility failed to document the dated witness signature on a consent form in 1 of 14 client records.
Client # 14 was admitted to the outpatient level of care on May 15, 2018 and was discharged on February 19, 2019. There was a consent to release information form on the managed care template, signed by the client; however, the consent form did not include a dated witness signature.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality Improvement has scheduled a Confidentiality & Consent refresher with the appropriate staff on April 1, 2019.
Additionally, the Director of Quality Improvement has add consent review to monthly compliance audits.
|
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
|
Observations
The facility failed to document the date, event or condition which the consent will expire on a consent form in 1 of 14 client records.
Client # 14 was admitted to the outpatient level of care on May 15, 2018 and was discharged on February 19, 2019. There was a consent to release information form on the managed care template, signed by the client; however, the form did not have a date, event, or a condition upon which the consent would expire.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality Improvement has scheduled a Confidentiality & Consent refresher with the appropriate staff on April 1, 2019.
Additionally, the Director of Quality Improvement has add consent review to monthly compliance audits.
|
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to document the written acknowledgement by the client that they had been notified of their client rights in one of seven client records reviewed.
Client # 7 was admitted on January 23, 2019 and was active at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
This was identified as a technology issue with signature pads that has been rectified by the IT Manager as of 3/11/2019. Additionally, The Director of Quality Improvement has scheduled a Confidentiality & Consents refresher, which included documentation/acknowledgement of client rights, with the appropriate staff on April 1, 2019. Memo will be sent on 3/18/2019 to review the expectation of consent review at each level of care. Director of Quality is initiating a Form committee to collectively review all internal consents/forms being used.
|
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
|
Observations
The facility failed to document that an individual treatment and rehabilitation plan was developed with the client in one of seven client records reviewed. Additionally, the facility failed to document which types of services and the frequency the client was to receive those services on the client's individual treatment plan in two client records reviewed.
Client # 1 was admitted on February 14, 2019 and was active at the time of the inspection. The comprehensive treatment plan was dated February 23, 2019. The type and frequency of services was not listed on the treatment plan. Additionally, the comprehensive treatment plan was not developed with and signed by the client.
Client # 4 was admitted on September 6, 2018 and was discharged on September 20, 2018. The comprehensive treatment plan was dated September 12, 2018. The type and frequency of services was not listed on the treatment plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The type and frequency of services has been identified as a technology issue and will be resolved by the Director of Quality Improvement and IT Manager in coordination with EMR system management by 3/22/2019.
A memo will go out to clinical staff regarding the treatment plan expectations by the Director of Quality Improvement by 3/25/2019.
Treatment plan/Treatment Plan updates are part of the Quality Compliance reports audited monthly.
|
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.
|
Observations
The facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice a week, in three of four applicable records reviewed in the partial hospitalization activity.
Client # 2 was admitted on February 13, 2019 and was active at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of February 17, 2019 to February 23, 2019 and February 24, 2019 to March 2, 2019.
Client # 3 was admitted on February 8, 2019 and was active at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of February 10, 2019 to February 16, 2019, February 17, 2019 to February 23, 2019, and February 24, 2019 to March 2, 2019.
Client # 5 was admitted on November 26, 2018 and was discharged on December 10, 2018. Documentation of two individual sessions per week was not completed for the week of December 2, 2018 to December 8, 2018.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality Improvement met with Program Managers to review service standards. Process reviewed on 3/15 that if a client misses their scheduled appointment a progress note will be put in the EMR.
This has been added by the Director of Quality Improvement to the current monthly compliance reports.
All active client charts were updated by March 25th. |
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.
|
Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in three of six applicable client records reviewed.
Client# 10 was admitted on July 31, 2018 and was active at the time of the inspection. The comprehensive treatment plan was completed on August 15, 2018 with an update due no later than October 15, 2018; however, the update was completed on November 13, 2018.
Client # 11 was admitted on June 12, 2018 and discharged on October 2, 2018. The comprehensive treatment plan was completed on June 11, 2018 with an update due no later than August 11, 2018; however, there was no update completed at the time of the inspection.
Client # 14 was admitted on May 5, 2018 and was discharged on February 19, 2019. A treatment plan update was completed on September 10, 2018 with an update due no later than November 2018; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Quality Improvement as implemented a weekly Treatment Plan update report which will flag all treatment plan updates that need to be completed. This report will go to Program Managers and will be added to monthly compliance report distributed organizationally. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
The facility failed to document follow-up information in four of four applicable client records reviewed.
Client # 11 was admitted on June 12, 2018 and was discharged on October 2, 2018.
Client # 12 was admitted on November 20, 2018 and was discharged on February 20, 2018.
Client # 13 was admitted on July 31, 2018 and was discharged on December 2, 2018.
Client # 14 was admitted on May 5, 2018 and was discharged on February 19, 2019
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The follow-up call process has been reassigned from Office Managers to Program Managers. The Director of Quality Improvement has revamped the follow-up call auditing procedures and reintroduced to program managers on 3/15. New reporting mechanisms will be distributed monthly for compliance.
|