INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 4 - 5, 2014 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Retreat at Lancaster County PA, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release client information form that complied with 709.28(c)(2) in one of ten client records.
The findings include:
Ten client records requiring documentation of an informed and voluntary consent to release client information form were reviewed on March 4-5, 2014. The facility failed to obtain an informed and voluntary consent to release client information form that complied with 709.28(c)(2) in client record #10.
Client # 10 was admitted on January 16, 2014 and was still an active client on March 5, 2014. The record contained a consent to release client information form that was signed by the client that did not include the specific information to be disclosed.
The findings were reviewed with the Facility Director.
|
Plan of Correction
All staff, admissions and clinical, will be informed that consents must be properly filled out and cannot release any information until this is completed. This will be monitored through chart checks done by Clinical Supervisor under the direction of Executive Director |
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.
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plans in two of four client records.
The findings include:
Four client records requiring documentation of the type and frequency of treatment and rehabilitation services on the individual treatment plan were reviewed on March 5, 2014. The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment plans in client records # 5 and 6.
The findings were reviewed with the Facility Director.
This is a repeat citation. The facility was previously cited for non-compliance on 4/17/13.
|
Plan of Correction
All clinical staff will be trained to complete treatment plans to ensure that type of services and frequency of services. This will be monitored via chart checks done by Clinical Supervisor under the direction of the executive director. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plans in two of four client records.
The findings include:
Four client records requiring documentation of support services on the individual treatment and rehabilitation plan were reviewed on March 5, 2014. The facility failed to document the proposed type of support services on the individual treatment plans contained in client records # 5 and 6.
The findings were reviewed confirmed by the Facility Director.
This is a repeat citation. The facility was previously cited for non-compliance on 4/17/13.
|
Plan of Correction
All clinical staff will be trained to complete treatment plans to include type of support services in all patient records. This will be monitored via chart checks done by clinical supervisor under the direction of Executive Director |