INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28-29, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Little Creek Lodge, LLC. 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of employee personnel records, the facility failed to document the required semi-annual performance evaluation in one of two counselor assistant records reviewed.
The findings include:
Four personnel records were reviewed on July 28, 2015. Two of four personnel records reviewed were for the counselor assistant position. The facility failed to document the required written semi-annual performance evaluation for Employee # 4.
Employee # 4 was hired as a residential care worker on 7/15/14 and was then promoted to the counselor assistant position on 10/8/14. The facility failed to document the required semi-annual performance evaluation for Employee # 4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted on July 28-29 in the application of Regulation 704.9(b) Licensure
The Clinical Director on 8/1/15 meet with Employee # 4 and reviewed 6 month performance evaluation as per requirements of Regulation 704.9(b) and this was signed by employee # 4 and Clinical Director and placed in Employee # 4?s employee training file.
To ensure that this does not reoccur Clinical Director will review all staff training records quarterly to ensure this requirement is being met. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations
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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 the review of client records, the facility failed to ensure that an informed and voluntary consent for the release of information was obtained from the client prior to the disclosure of information contained in the client record in one of ten client records reviewed.
The findings include:
Ten client records requiring informed and voluntary consent to release information forms were reviewed on July 28, 2015 and July 29, 2015. The facility failed to ensure that an informed and voluntary consent to release information was obtained in client record # 3.
Client # 3 was admitted into treatment on 4/13/15 and was discharged on 7/9/15. The client's record contained documentation of the facility's correspondence with another drug and alcohol treatment facility, in which the client's discharge and aftercare plan were discussed. However, the client's record did not contain a consent to release form for the other drug and alcohol facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted on July 28-29 in the application of Regulation 709.28 Confidentiality(c)
The Clinical Director will schedule training on Confidentially and Release of Information forms for all clinical staff. Therefore ensuring all clinical staff are knowledgeable of release of information forms needed and confidentially regulations. This training will be held by 9/30/15
To ensure that this does not reoccur Clinical Director will review all client charts monthly to ensure this requirement is being met. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment services on the individual treatment and rehabilitation plan in ten of ten client records reviewed.
The findings include:
Ten client records requiring documentation of the frequency of treatment services on the individual treatment and rehabilitation plans were reviewed during the renewal inspection on July 28, 2015 and July 29, 2015. The individual treatment and rehabilitation plans contained in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 did not include the frequency of treatment services.
Client # 1 was admitted into treatment on 6/2/15 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan dated 6/2/15 did not specify the frequency of individual and group counseling therapy.
Client # 2 was admitted into treatment on 6/22/15 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan dated 6/22/15 did not specify the frequency of individual and group counseling therapy.
Client # 3 was admitted into treatment on 4/13/15 and was discharged on 7/9/15. The client's individual treatment and rehabilitation plan dated 4/13/15 did not specify the frequency of individual and group counseling therapy.
Client # 4 was admitted into treatment on 2/28/15 and was discharged on 3/25/15. The client's individual treatment and rehabilitation plan dated 2/28/15 did not specify the frequency of individual and group counseling therapy.
Client # 5 was admitted into treatment on 1/31/15 and was discharged on 5/2/15. The client's individual treatment and rehabilitation plan dated 1/31/15 did not specify the frequency of individual and group counseling therapy.
Client # 6 was admitted into treatment on 4/13/15 and was discharged on 7/9/15. The client's individual treatment and rehabilitation plan dated 4/13/15 did not specify the frequency of individual and group counseling therapy.
Client # 7 was admitted into treatment on 9/3/14 and was discharged on 11/29/14. The client's individual treatment and rehabilitation plan dated 9/3/14 did not specify the frequency of individual and group counseling therapy.
Client # 8 was admitted into treatment on 9/15/14 and was discharged on 1/4/15. The client's individual treatment and rehabilitation plan dated 9/15/14 did not specify the frequency of individual and group counseling therapy.
Client # 9 was admitted into treatment on 8/17/14 and was discharged on 11/14/14. The client's individual treatment and rehabilitation plan dated 8/17/14 did not specify the frequency of individual and group counseling therapy.
Client # 10 was admitted into treatment on 12/12/14 and was discharged on 12/23/14. The client's individual treatment and rehabilitation plan dated 12/12/14 did not specify the frequency of individual and group counseling therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted on July 28-29 in the application of Regulation 704.52(a)(2) TX type & frequency
The Clinical Director on 8/4/15 meet with clinical employees. Clinical Director reviewed regulation 704.52(a)(2) regarding type and frequency of treatment and rehabilitation services required as per policy and procedures. Staff was instructed on ensuring these were included on all treatment plans.
To ensure that this does not reoccur Clinical Director will review all client treatment plans monthly to ensure this requirement is being met. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations
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