This report is a result of an on-site licensure renewal inspection conducted on September 25, 2019 through September 26, 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, Little Creek Lodge, LLC. was found not 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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Observations
The facility failed to properly document a complete client record, as there was no documentation in the client's treatment and rehabilitation plan that any work done, by the client, at the project is an integral part of the plan in seven of seven client records reviewed.
Client #1 was admitted on October 11, 2018 and was discharged on January 7, 2019.
Client #2 was admitted on November 22, 2018 and was discharged on February 19, 2019.
Client #3 was admitted on December 13, 2018 and was discharged on March 12, 2019.
Client #4 was admitted on May 21, 2019 and was discharged on August 1, 2019.
Client #5 was admitted on May 7, 2019 and was active at the time of the inspection.
Client #6 was admitted on July 22, 2019 and was active at the time of the inspection.
Client #7 was admitted on August 13, 2019 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients who participate in domestication/work therapy while in treatment will have this work be integrated into their individualized treatment plan. This will be done upon admission and throughout the client's treatment, as necessary.
The Clinical Director made all Clinicians aware of this directive during a clinical meeting post-site survey on 9/30/19. Given that this is something that has been addressed previously and not implemented consistently, the Clinical Director is requiring that Clinicians either have the Clinical Director review and sign off on all Treatment Plan Goals and Objectives, or provide the Clinical Director with proof during weekly clinical team meetings, that this is being done. Weekly clinical team meetings occur every Thursday at 3:00 pm.
Ultimately, the Clinical Director is responsible for reviewing each active chart on a monthly basis to ensure domestication/work therapy is integrated into each client's treatment if deemed appropriate given each client's individualized needs. |