INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 3, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to conduct a fire drill during facility sleeping hours at least once every 6 months during the entire period of October 2017 through September 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A fire drill was conducted on October 17, 2018 at 12:30 am. The next fire drill occurring during sleeping hours is scheduled for May 2019. The Director of Residential Care will meet with the Clinical Director on a monthly basis to review the current month's drill and outcome, and they will schedule a drill for the following month. This monthly meeting will be used to assure drills are being conducted on alternating shifts with different staff members in order to assure all staff are properly trained. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The facility failed to provide documentation of an annual financial audit of the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Owners contacted 5 Certified Public Accountants between 10/3/18 and 10/4/18, in order to have the Audit for FY 2017 completed properly. This audit will be completed by 12/31/18 and an audit for FY 2018 will be scheduled with said CPA will occur no later than 7/1/19. Both audits will remain on file. The Project Director will assure the hired CPA includes a letter indicating an audit was performed using generally accepted accounting principles, and contains an opinion on the results found. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one of two applicable records reviewed.
Client #5 was admitted on July 27, 2018 and was administratively discharged on September 11, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility maintains an Involuntary Intent to Discharge Form that is reviewed with clients who may be moving towards being involuntarily discharged. However, this form was not reviewed with Client #5 prior to his discharge and was not added to his chart.
This case was reviewed by the Clinical Director with the Counselor assigned to the case on 10/5/18. The process of placing someone on an Intent to Discharge and the accompanying form was reviewed with all Clinical Staff in a staff meeting on Thursday 10/11/18. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
The facility failed to provide documentation of the verification that work done by the client at the project is an integral part of the client's treatment plan in seven of seven client records reviewed. Additionally, the facility failed to document case consultation notes in one of seven client records reviewed.
Client #1 was admitted on September 4, 2018 and was still active at the time of the inspection.
Client #2 was admitted on July 17, 2018 and was still active at the time of the inspection.
Client #3 was admitted on August 9, 2018 and was still active at the time of the inspection.
Client #4 was admitted on October 18, 2017 and was discharged on November 24, 2017. The client record did not contain documentation of case consultation notes, in addition no verification of work done at project is a part of the treatment plan.
Client #5 was admitted on July 27, 2018 and was discharged on September 11, 2018.
Client #6 was admitted on June 7, 2018 and was discharged on September 13, 2018.
Client #7 was admitted on February 22, 2018 and was discharged on April 19, 2018.
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. The Clinical Director made all Clinicians aware of this directive during a Staff Meeting on 10/11/18 and examples of appropriate treatment goals and plans were reviewed. 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.
In re: to case consultations. The Clinical Director will initiate all case consultation appointments with individual Counselors, on a monthly basis, to ensure all cases are being consulted on each month. The Clinical Director will also review all charts monthly, to ensure these case consultation meetings are being documented properly. |