INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2, 2016 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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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.
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Observations
The findings include:
4 Pa. Code 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 into drug or alcohol abuse and the frequency of such relapse.
Ten client records were reviewed on August 2, 2016. The facility released information that exceeded the limitations imposed under 4 Pa. Code 255.5 in client records # 1, 3, 4, 5, 6 and 9.
Client #1 - Consent to release form dated April 22, 2016 for a insurance company, allowed for the release of the following documents: medication record
Client #3 - Consent to release form dated June 2, 2016 for a insurance company, allowed for the release of the following documents: medication record
Client #4 - Consent to release form dated June 8, 2016 for a insurance company, allowed for the release of the following documents: medication record
Client #5- Consent to release form dated June 14, 2016 for a insurance company, allowed for the release of the following documents: medication record
Client #6 - Consent to release form dated April 25, 2016 for a insurance company, allowed for the release of the following documents: medication record
Client #9 - Consent to release form dated December 18, 2015 for a insurance company, allowed for the release of the following documents: medication record
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 August 1-2, 2016, in the application of Regulation § 709.28. Confidentiality. (c).
Clinical Director held an in-house training on Confidentiality and Release of Information forms, for all Clinical Staff, on September 1, 2016. Additionally, all Clinical Staff have been registered for the DDAP Confidentiality training on 10/4/16, therefore ensuring all Clinical Staff are knowledgeable of Release of Information forms needed and Confidentiality regulations.
To ensure that this does not reoccur, Clinical Director will review all client charts monthly, therefore meeting DDAP requirements as stated in the DDAP Licensing Regulations.
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709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
The findings include:
Ten client records were reviewed on August 2, 2016. All were reviewed for individualized treatment and rehabilitation plans which are to be developed with the client. Client records # 1, 3, 4, 5, 6, 7, 8, 9 and 10 did not contain an individualized treatment and rehabilitation plan that was developed with the client.
Client #1 was admitted on April 22, 2016 and their individualized treatment and rehabilitation plan was developed and signed by staff on May 22, 2016. The treatment plan was not signed by the client.
Client #2 was admitted on June 10, 2016 and their individualized treatment and rehabilitation plan was developed and signed by staff on July 10, 2016. The treatment plan was not signed by the client.
Client #3 was admitted on June 2, 2016 and their individualized treatment and rehabilitation plan was developed and signed by staff on June 3, 2016. The treatment plan was not signed by the client.
Client #4 was admitted on June 8, 2016 and their individualized treatment and rehabilitation plan was developed and signed by staff on June 8, 2016. The treatment plan was not signed by the client.
Client #5 was admitted on June 14, 2016 and their individualized treatment and rehabilitation plan was developed and signed by staff on June 16, 2016. The treatment plan was not signed by the client.
Client #6 was admitted on April 25, 2016 and their individualized treatment and rehabilitation plan was developed and signed by staff on April 25, 2016. The treatment plan was not signed by the client.
Client #7 was admitted on April 11, 2016 and their individualized treatment and rehabilitation plan was developed and signed by staff on May 16, 2016. The treatment plan was not signed by the client.
Client #8 was admitted on December 18, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on January 19, 2016. The treatment plan was not signed by the client.
Client #9 was admitted on December 18, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on January 18, 2016. The treatment plan was not signed by the client.
Client #10 was admitted on December 21, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on January 21, 2016. The treatment plan was not signed by the client.
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 August 1-2, 2016, in the application of Regulation 709.52 (a).
Clinical Director held an in-house training on Case Management and Treatment Plan Development, for all Clinical Staff, on September 1, 2016. Additionally, a signature line has been added to the Treatment Plan platform in ECR, allowing clients to sign each treatment plan as they are created with their Counselor. This signature verifies client involvement in the development of each of their treatment goals, therefore ensuring all Clinical Staff are knowledgeable of regulations regarding Treatment Plan Development.
To ensure that this does not reoccur, Clinical Director will review all client charts monthly, therefore meeting DDAP requirements as stated in the DDAP Licensing Regulations.
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