INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical site inspection on August 11, 2021, the facility failed to ensure that hot water temperatures did not exceed 120 degrees Fahrenheit.
The water temperature in all bathrooms read 130 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director met with Lead Administrator and Operations Manager to discuss water temperature. Reviewed regulation 705.6(3) indicating water temperature may not exceed 120 degrees F. Assured boiler temperature set below that at 115 degress F. |
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.
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Observations
Based on a review of seven client records on August 11, 2021, 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 four records reviewed.
Client #1 was admitted on May 17, 2021 and was active at the time of the inspection. A consent to release information to probation dated May 19, 2021 included medical history, laboratory test results, psychiatric history and psychiatric assessment evaluations.
Client #2 was admitted on May 19, 2021 and was active at the time of the inspection. A consent to release information to a health insurance provider dated June 9, 2021, included progress notes, medical history, medical progress notes and assessments, lab test results, psychiatric history and evaluations and family information.
Client #3 was admitted on June 2, 2021 and was active at the time of the inspection. A consent to release information to probation dated June 7, 2021 included treatment plans, medical progress notes and assessments, lab test results, psychiatric history and evaluations and family information.
Client #7 was admitted on May 12, 2021 and was discharged on July 13, 2021. A consent to release information to probation on May 12, 2021, included progress updates, medical history, medical progress reports, laboratory test results, psychiatric history and assessment evaluations and family information.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from the licensing inspection held on April 21, 2021.
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Plan of Correction
Clinical Director conducted an in-person Clinical team meeting on 8/19/21. The program's confidentiality policy and associated commonwealth law 4 Pa Code 255.5 what distributed to each member and reviewed. Laws around release of information to legal entities were discussed. A blank 255.5 ROI, specifically labeled to be used with legal, county and insurance entities, was added to the client admission packet on 5/5/21 after the past inspection and the Clinical Director reminded the Clinical Team of that. This form will now be completed with the client immediately upon admission with the other admission consents and paperwork. These ROI's only contain the 5 items permitted to be released to these entities with the client's signed consent. Clinical Director will continue to audit completed admission paperwork for clients for the next 2 months, or until these forms are being properly completed 100% of the time over a 2 week period. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
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Observations
Based on a review of seven client records on August 11, 2021, the facility failed to include follow-up information in one out of three applicable records reviewed.
Client #5 was admitted on March 8, 2021 and was discharged on June 5, 2021. There was no documentation of follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director met with Alumni Coordinator and Clinical Team members on 8/18/2021 to review the facility's follow-up call policy. Advised the Clinicians to notify Alumni Coordinator when client is preparing to discharge at which time, Alumni Coordinator will verify contact information and inform client of follow-up call to come upon discharge. Finally, directed Alumni Coordinator to adhere to follow-up call policy of calling clients within 1 month, 3 months, 6 months, and 1 year from date of discharge. Walked Alumni Coordinator through how to document follow-up calls in EMR system. |