INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 15-17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. 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.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the observation which occurred during the physical plant tour, the facility failed to ensure privacy in counseling sessions.
The findings include:
The physical plant tour took place on April 17, 2013 around 2pm. The "school house" is a buildings that provided clinical services. The interior doors on several of the rooms were observed to have small window panels that were not covered to provide privacy for those participating in counseling sessions. An observer would be able to view group and individual sessions through the glass panels. An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
there have been blinds placed on each of these windows in the schoolhouse.
this will ensure the privacy of all patients and staff for all services provided in the schoolhouse. Exec Dir will ensure the blinds stay intact. |
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 the physical plant tour, the facility failed to ensure that the hot water temperature did not exceed 120F.
The findings include:
The physical plant tour took place on April 17, 2013 around 2pm. The client bathrooms and staff restrooms on the 2nd, 3rd and 4th floors of the residential facility exceeded the required water temperature of 120F. The water temperature in each bathroom and restroom registered in at 140F. Also, the "school house" where counseling sessions are conducted also had restrooms for clients and staff that exceeded the required water temperature of 120F. The water temperature in each bathroom and restroom registered in at 140F.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
the water heater will be turned down so the water temp does not exceed 120 degrees. this will be ensured by the exec dir and maintained by the facilities manager. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on April 15, 2013. The fire drills conducted from April 2012 - March 2013 were reviewed. Per regulation, the residential facility shall prepare alternate exit routes to be used during fire drills. The facility only documented what exit was obstructed during fire drills for the following months: April 2012, May 2012, June 2012, July 2012, August 2012, September 2012, October 2012, November 2012, December 2012, January 2013, February 2013 and March 2013.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
at the next fire drill and all forthcoming fire drills, alternate routes will be planned for the patients and the route used will be documented in the fire drill. this will be maintained and ensured by the exec dir |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of the project's policies and procedures manual and client records on April 15 - 17, 2013 it was determined that the facility failed to provide documentation that verbal medication orders were signed within 24 hours by the prescribing physician. A review of the project's policies and procedures manual on April 15, 2013 indicated that all verbal orders would be put in writing and signed within 24 hours by the prescribing physician and fifteen client records were reviewed on April 16, 2013. An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
the medical record system will be reviewed to ensure that there is proper documentation of verbal orders for medications. the medical staff, physicians, will be educated on this process and will ensure documentation of verbal orders being signed off. This will be maintained, checked on and ensured by the executive director. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document components of the physical exams in three of six client records.
The findings include:
Fifteen client records were reviewed on April 16, 2013. The physical examination documentation was required in six client records, #1, 2, 3, 4, 5 and 6. The physical exams are required to have the following documentation; date of the exam, vital signs, review of the clients organ system, clients general appearance and the physician's impressions of the client. The following client records failed to have the general appearance and the physician's impression of the client's documented on their physical exams, #1, 5 and 6. An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
a meeting and training will be held with the medical staff, all physicians, to ensure that they complete all pt physical exams including general appearance and clinical impressions. it will be maintained via daily chart checks to ensure this is complete by the exec dir. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in five of six short-term detoxification.
The findings include:
Fifteen client records were reviewed on April 16, 2013. Six of the fifteen client records were reviewed from the short-term detoxification activity. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records # 3, 4 and 5 and did not include a composite picture of the client.
The psychosocial evaluations in client records # 3, 4 and 5 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 3, 4 and 5 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records # 3, 4 and 5 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 3, 4 and 5 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records # 3, 4 and 5 did not include an evaluation of the counselor conclusions/impressions of the client.
Also, based on the review of the facility's policy and procedure manual, psychosocial evaluations are to be completed within 2 days of the clients admission date.
Client #1 was admitted on March 25, 2013 and discharged on March 29, 2013. The psychosocial evaluation was to be completed by March 27, 2013. As of the date of the licensing inspection, April 15-17, 2013, there was no documentation of client #1's psychosocial evaluation.
Client #6 was admitted on April 11, 2013 and the psychosocial evaluation was to be completed by April 13, 2013. As of the date of the licensing inspection, April 15-17, 2013, there was no documentation of client #6's psychosocial evaluation.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
Clinical staff will be attending a training on completion of psychosocial evaluations to ensure that assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment are included in all patient records they complete assessments on.
These items are currently included in the clinical formulation, which is a separate document than the psychosocial assessment. The Clinical Formulation will be part of the entire assessment.
Daily chart checks by clinical supervisors under direction of executive director will ensure the maintaining of this practice. |
709.63(a)(4) LICENSURE Medication records
709.63. 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:
(4) Medication records.
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Observations
Based on a review of client records, the facility failed to not document the initial detox protocol by the physician in five of six client records.
The findings include:
Fifteen client records were reviewed on April 16, 2013. Six client records were reviewed from the short-term detoxification records, #1, 2, 3, 4, 5 and 6. Of the six, five did not show documentation for the initial detox protocols by the physician, #1, 3, 4, 5 and 6. Documentation in client records revealed an assessment by the nursing staff that was performed by identification for a detox protocol pertaining to the client ' s drug of choice. An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
Physicians will be trained to ensure that there is documentation of an assessment by the physician to ensure detox protocol in all patient records. Executive Director will meet with medical staff to review this process. Daily chart checks will be done to ensure maintaining of this practice. |
709.63(a)(5) LICENSURE Record of Services
709.63. 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:
(5) Record of services provided.
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Observations
Based on a review of client records, the facility failed to provide a record of service in six of six records reviewed.
The findings include:
Fifteen client records were reviewed on April 16, 2013. Six of the fifteen client records were reviewed from the short-term detoxification activity, #1, 2, 3, 4, 5 and 6. The facility failed to have available record of service documentation in all records reviewed, #1, 2, 3, 4, 5 and 6.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
The record of service will be able to be demonstrated thru a screen shot or a report that shows ONLY the services provided. Executive Director will review the medical record system to ensure this practice and the maintaining of this practice. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to include components in the discharge summary.
The findings include:
Fifteen client records were reviewed on April 16, 2013. Six of the fifteen client records were reviewed from the short-term detoxification activity, #1, 2, 3, 4, 5 and 6. Two of the six were discharge clients, #1 and 2. The facility failed to include reason for treatment on the discharge summary for client's #1 and 2.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
Executive director will meet with clinical team, including therapists and clinical supervisors to review discharge summaries and to ensure that they include the reason for treatment in each summary they complete. This will be ensured by daily chart checks by the clinical supervisor under the direction of the executive director. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document components of the physical exams in nine of nine client records.
The findings include:
Fifteen client records were reviewed on April 16, 2013. The physical examination documentation was required in nine client records, #7, 8, 9, 10, 11, 12, 13, 14 and 15. The physical exams are required to have the following documentation; date of the exam, vital signs, review of the clients organ system, clients general appearance and the physician's impressions of the client. The following client records failed to have the general appearance and the physician's impression of the client's documented on their physical exams, #7, 8, 9, 10, 11, 12, 13, 14 and 15.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
Physicians were met with to discuss that general appearance and physical impressions must be included in all physical exams that they complete. This will be monitored via chart checks weekly to ensure this practice by the Exec Dir. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in nine of nine residential treatment and rehabilitation records.
The findings include:
Fifteen client records were reviewed on April 16-17, 2013. Nine of the fifteen client records were reviewed from the residential treatment and rehabilitation activity. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records # 7, 8, 9, 10, 11, 12, 13 and 15 and did not include a composite picture of the client.
The psychosocial evaluations in client records # 7, 8, 9, 10, 11, 12, 13 and 15 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 7, 8, 9, 10, 11, 12, 13 and 15 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records # 7, 8, 9, 10, 11, 12, 13 and 15 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 7, 8, 9, 10, 11, 12, 13 and 15 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records # 7, 8, 9, 10, 11, 12, 13 and 15 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in five of six short-term detoxification.
These items are demonstrated in the clinical formulation for each patient and is a separate document from the psychosocial assessment. All clinical staff will be trained to ensure these items are included in all clinical formulations and this will be part of the entire psychosocial assessment process. This will be monitored by chart checks by clinical supervisors under the direction of the exec dir |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in nine of nine client records.
The findings include:
Fifteen client records were reviewed on April 16, 2013. Nine of the fifteen client records were reviewed from the residential treatment and rehabilitation activity, #7, 8, 9, 10, 11, 12, 13, 14 and 15. Preliminary treatment plans were required in fifteen client records. The facility's policy, states that the preliminary treatment plan will be documented within 2 days of the clients admission date. The facility failed to document preliminary treatment plans in client records #7, 8, 9, 10, 11, 12, 13, 14 and 15.
Client #7 was admitted on March 6, 2013 and discharged on April 3, 2013. The preliminary plan was to be documented by March 8, 2013. As of the date of the licensing inspection April 15 - 17, 2013 client #7's preliminary treatment plan was not documented.
Client #8 was admitted on March 14, 2013 and discharged on April 12, 2013. The preliminary plan was to be documented by March 16, 2013. As of the date of the licensing inspection April 15 - 17, 2013 client #8's preliminary treatment plan was not documented.
Client #9 was admitted on March 1, 2013 and discharged on March 27, 2013. The preliminary plan was to be documented by March 3, 2013. As of the date of the licensing inspection April 15 - 17, 2013 client #9's preliminary treatment plan was not documented.
Client #10 was admitted on March 6, 2013 and discharged on April 4, 2013. The preliminary plan was to be documented by March 8, 2013. As of the date of the licensing inspection April 15 - 17, 2013 client #10's preliminary treatment plan was not documented.
Client #11 was admitted on March 18, 2013 and discharged on April 13, 2013. The preliminary plan was to be documented by March 20, 2013. As of the date of the licensing inspection April 15 - 17, 2013 client #11's preliminary treatment plan was not documented.
Client #12 was admitted on March 25, 2013 and the preliminary plan was to be documented by March 27, 2013. As of the date of the licensing inspection April 15 - 17, 2013 client #12's preliminary treatment plan was not documented.
Client #13 was admitted on March 29, 2013 and the preliminary plan was to be documented by March 31, 2013. As of the date of the licensing inspection April 15 - 17, 2013 client #13's preliminary treatment plan was not documented.
Client #14 was admitted on April 14, 2013 and the preliminary plan was to be documented by April 16, 2013. As of the date of the licensing inspection April 15 - 17, 2013 client #14's preliminary treatment plan was not documented.
Client #15 was admitted on March 20, 2013 and the preliminary plan was to be documented by March 22, 2013. As of the date of the licensing inspection April 15 - 17, 2013 client #15's preliminary treatment plan was not documented.
An interview with the project director/facility director on April 17, 2013 confirmed the findings
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Plan of Correction
Clinical staff will be trained to ensure that they include a preliminary treatment plan for each patient. This will occur within 2 days of patient's admission. This will be maintained via daily chart checks by the clinical supervisor under the direction of the exec dir |
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.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of eight client records.
The findings included:
Fifteen client records were reviewed on April 16, 2013. Nine of the fifteen client records were reviewed from the residential treatment and rehabilitation activity, #7, 8, 9, 10, 11, 12, 13, 14 and 15. The type and frequency of services was required in the individual treatment and rehabilitation plan in eight client records. Four of the eight client records did not contain documentation of type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
Client #7 was admitted on March 6, 2013 and discharged on April 3, 2013. An individual treatment and rehabilitation plan was completed on March 10, 2013, but did not document the type and frequency.
Client #8 was admitted on March 14, 2013 and discharged on April 12, 2013. An individual treatment and rehabilitation plan was completed on March 16, 2013, but did not document the type and frequency.
Client #10 was admitted on March 6, 2013 and discharged on April 4, 2013. An individual treatment and rehabilitation plan was completed on March 6, 2013, but did not document the type and frequency.
Client #15 was admitted on March 20, 2013 and an individual treatment and rehabilitation plan was completed on April 4, 2013, but did not document the type and frequency.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
Clinical staff will be trained to include frequency and type of services on each treatment plan for each of their patients. This will be maintained by daily chart reviews by the clinical supervisor under the direction of the exec dir |
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.
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Observations
Based on the review of client records, the facility failed to document the support services on the individual treatment and rehabilitation plan in seven of eight client records.
The findings included:
Fifteen client records were reviewed on April 16, 2013. Nine of the fifteen client records were reviewed from the residential treatment and rehabilitation activity, #7, 8, 9, 10, 11, 12, 13, 14 and 15. The support services were required in the individual treatment and rehabilitation plan in eight client records. Seven of the eight client records did not contain documentation of support services on the individual treatment and rehabilitation plan.
Client #7 was admitted on March 6, 2013 and discharged on April 3, 2013. An individual treatment and rehabilitation plan was completed on March 10, 2013, but did not document support services.
Client #8 was admitted on March 14, 2013 and discharged on April 12, 2013. An individual treatment and rehabilitation plan was completed on March 16, 2013, but did not document support services.
Client #10 was admitted on March 6, 2013 and discharged on April 4, 2013. An individual treatment and rehabilitation plan was completed on March 6, 2013, but did not document support services.
Client #11 was admitted on March 18, 2013 and discharged on April 13, 2013. An individual treatment and rehabilitation plan was completed on March 18, 2013, but did not document support services.
Client #12 was admitted on March 25, 2013 and an individual treatment and rehabilitation plan was completed on April 5, 2013, but did not document support services.
Client #13 was admitted on March 29, 2013 and an individual treatment and rehabilitation plan was completed on April 11, 2013, but did not document support services.
Client #15 was admitted on March 20, 2013 and an individual treatment and rehabilitation plan was completed on April 4, 2013, but did not document support services.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
Each treatment plan that is completed for each patient will include support services. The clinical staff will be trained to ensure each treatment plan includes this. This will be maintained by the Exec Dir and will be monitored via daily chart checks by the clinical supervisor. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to provide a record of service in nine of nine records reviewed.
The findings include:
Fifteen client records were reviewed on April 16, 2013. Nine of the fifteen client records were reviewed from the residential treatment and rehabilitation activity, #7, 8, 9, 10, 11, 12, 13, 14 and 15. The facility failed to have available record of service documentation in all records reviewed, #7, 8, 9, 10, 11, 12, 13, 14 and 15.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
the record of services will need to be a screenshot of what is existing in the medical record system currently. Executive Director will work with the system to ensure this is able to happen and provide the record of service. there is a report that may be able to be run to demonstrate the record of service and this can be an option that will be provided to ensure a record of service snapshot for all patient records. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to include components in the discharge summary.
The findings include:
Fifteen client records were reviewed on April 16, 2013. Nine of the fifteen client records were reviewed from the residential treatment and rehabilitation activity, #7, 8, 9, 10, 11, 12, 13, 14 and 15. Five of the nine were discharge clients, #7, 8, 9, 10 and 11. The facility failed to include reason for treatment on the discharge summary for client's #7, 8, 9, 10 and 11.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
exceutive director will educate all therapist and clinical supervisors to ensure that each DC summary they complete includes the patient's reason for treatment. this will be maintained and ensured via daily chart checks by the clinical supervisors under the direction of the executive director. |