INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.Employee #10, who was hired as a counselor on April 4, 2022, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience. This finding was reviewed with facility staff during the licensing inspection.This is a repeat citation from the October 12, 2021 licensing inspection.
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Plan of Correction
HR Manager will review DDAP standards for educational and experiential qualifications for counselors. By 7/15/2022, HR manager will retrain all clinical hiring managers and HR personnel on DDAP standards. Moving forward, HR manager will ensure that all clinical hiring managers are aware of the standards with ongoing training as needed.
The referenced employee (employee #10) has been removed from her position as a counselor and been placed in a clinical support role until she meets the requirement of one (1) year of clinical experience. Employee will be placed back in counselor role upon completion of entire year of clinical experience and required supervision.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 7/1/2022, Facilities Manager will have facilities team restock individual paper towels into all paper towel dispensers, and ensure that paper towels are being restocked as needed. Facilities manager will ensure that facilities team is completing walkthroughs regularly to ensure that all paper towels are stocked.
Executive Director will ensure completion of project and ongoing compliance by continuous follow up with facilities manager.
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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 patient records, the facility failed to keep disclosures of patient identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in patient records in nine out of ten records reviewed.Patient #1 was admitted on May 9, 2022 and was still active at the time of the inspection. A consent to release information to a funding source dated May 9, 2022 allowed for the release of type and frequency of services. Additionally, "other" was checked with no specific information to be released.Patient #5 was admitted on February 15, 2022 and discharged February 19, 2022. A consent to release information to a funding source dated April 8, 2022 allowed for the release of demographic information including identification and status as a Retreat Behavioral Health program patient, diagnosis and related information, history and physical, bio-psych-social assessment, type and frequency of services, discharge summary, transition, continuing care plan, provider notes and consultation reports- excluding psychotherapy notes, counseling logs- encounter start and stop times, test results and report- excludes toxicology, prescription regimen and dosing records, and AIDS/HIV/ARC- diagnosis/testing/treatment. Additionally, "other" was checked with no specific information to be released.Patient #7 was admitted on February 14, 2022 and was discharged on March 10, 2022. A consent to release information to a funding source dated March 1, 2022 allowed for the release of type and frequency of services. Additionally, "other" was checked with no specific information to be released.Patient #8 was admitted on April 8, 2022 and was still active at the time of the inspection. A consent to release information to a funding source dated April 8, 2022 allowed for the release of demographic information including identification and status as a Retreat Behavioral Health program patient, diagnosis and related information, history and physical, bio-psych-social assessment, type and frequency of services, discharge summary, transition, continuing care plan, provider notes and consultation reports- excluding psychotherapy notes, counseling logs- encounter start and stop times, test results and report- excludes toxicology, prescription regimen and dosing records, and AIDS/HIV/ARC- diagnosis/testing/treatment. Additionally, "other" was checked with no specific information to be released.Patient #9 was admitted on April 11, 2022 and was still active at the time of the inspection. A consent to release information to a funding source dated April 11, 2022 allowed for the release of type and frequency of services. Additionally, "other" was checked with no specific information to be released. A consent to release information to a government agency dated April 11, 2022 allowed for the release of discharge summary. Additionally, "other" was checked with no specific information to be released.Patient #11 was admitted March 1, 2022 and was discharged on March 29, 2022. A consent to release information to a funding source dated March 1, 2022 "other" was checked with no specific information to be released.Patient #12 was admitted on March 12, 2022 as was still active at the time of the inspection. A consent to release information to a funding source dated March 12, 2022 allowed for the release of type and frequency of services. Additionally, "other" was checked with no specific information to be released.Patient #13 was admitted on March 12, 2022 and was still active at the time of the inspection. A consent to release information to a funding source dated May 12, 2022 allowed for the release of demographic information including identification and status as a Retreat Behavioral Health program patient, diagnosis and related information, history and physical, bio-psych-social assessment, type and frequency of services, discharge summary, transition, continuing care plan, provider notes and consultation reports- excluding psychotherapy notes, counseling logs- encounter start and stop times, test results and report- excludes toxicology, prescription regimen and dosing records, and AIDS/HIV/ARC- diagnosis/testing/treatment. Additionally, "other" was checked with no specific information to be released.Patient #14 was admitted on May 11, 2022 and was still active at the time of the inspection. A consent to release information to a funding source dated May 11, 2022 allowed for the release of demographic information including identification and status as a Retreat Behavioral Health program patient, diagnosis and related information, history and physical, bio-psych-social assessment, type and frequency of services, discharge summary, transition, continuing care plan, provider notes and consultation reports- excluding psychotherapy notes, counseling logs- encounter start and stop times, test results and report- excludes toxicology, prescription regimen and dosing records, and AIDS/HIV/ARC- diagnosis/testing/treatment. Additionally, "other" was checked with no specific information to be released.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director of Quality Assurance will review 4 Pa. Code 255.5 (b) regarding limits on disclosures of patient identifying information.
By 7/15/2022, Director of Quality Assurance will retrain applicable staff on maintaining appropriate limits on disclosures of patient identifying information. Quality Assurance staff will ensure compliance with weekly chart audits. Any consents found that are not correctly filled out will be adjusted by Quality Assurance staff and resigned by patient. Director of Quality Assurance will continue retrain applicable staff members as needed.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of patient records, the facility failed to document a completed consent to release information in one out of ten records reviewed, as there was a form that was missing purpose of disclosure.Patient #4 was admitted on December 22, 2021 and was discharged January 21, 2022. There was a consent to release form, signed and dated on December 23, 2021 to a funding source. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 7/15/2022, Director of Quality Assurance will review and retrain applicable staff on appropriate completion of consent to release information documentation. Quality Assurance staff will ensure compliance with weekly chart audits. Director of Quality Assurance will continue to retain applicable staff as needed. |
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
Based on a review of patient records, the facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project, including reason for termination in one out of one applicable record.Patient #5 was admitted on February 15, 2022 and was discharged on February 19, 2022. There was no documentation of a letter sent.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 7/1/2022, Policy and Procedures Administrator has drafted and implemented the following policy:
Shift Administrator on duty will provide patient with reason for involuntary discharge via written document prior to discharge or via document uploaded to patient portal.
Director of Quality Assurance will retrain applicable staff on the new policy. Director of Quality Assurance will oversee compliance of this policy with weekly chart audits.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of patient records, the facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project, including that the patient shall have an opportunity to request reconsideration of a decision terminating treatment in one out of one applicable record.Patient #5 was admitted on February 15, 2022 and was discharged on February 19, 2022. There was no documentation of a letter sentThis finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 7/1/2022, Policy and Procedures Administrator has drafted and implemented the following policy:
Shift Administrator will provide patient with reason for involuntary discharge as well as procedure to request reconsideration of a decision terminating treatment via written document prior to discharge or via document uploaded to patient portal.
Executive Director will review and make final determination on all requests for reconsideration of a decision terminating treatment.
Director of Quality Assurance will retrain all applicable staff on new policy. Director of Quality Assurance will oversee compliance of this policy.
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709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of patient records, the facility failed to complete treatment plans within the regulatory timeframe in five six of seven patient records reviewed.Patient #1 was admitted on May 9, 2022 and was still active at the time of the inspection. A treatment plan was due no later than May 14, 2022 and was not completed until May 17, 2022.Patient #2 was admitted on April 13, 2022 and was still active at the time of the inspection. A treatment plan was due no later than April 18, 2022 and was not completed until April 21, 2022.Patient #3 was admitted on April 18, 2022 and was still active at the time of the inspection. A treatment plan was due no later than April 23, 2022 and was not completed until April 25, 2022.Patient #4 was admitted on December 27, 2022 and was discharged January 21, 2022. A treatment plan was due no later than January 2, 2022 and was not completed until January 6, 2022. Patient #6 was admitted on March 8, 2022 and was discharged March 29, 2022. A treatment plan was due no later than March 13, 2022 and was not completed until March 24, 2022.Patient #7 was admitted on February 14, 2022 and was discharged on March 10, 2022. A treatment plan was due no later than February 19, 2022 and was not completed until February 28, 2022.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 7/1/2022, Policy and Procedures Administrator has drafted and implemented the following policy:
Clinical staff will complete initial treatment plan within 72 hours of patient's advance to rehab status (ATR).
Clinical Director will retrain all applicable staff on policy. Clinical Director will oversee compliance of this policy with weekly chart audits.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of two patient records reviewed.Patient #3 was admitted on April 18, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 25, 2022 and the next update was due no later than May 7, 2022; however, it was not completed until May 12, 2022.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 7/1/2022, policy and procedures administrator has drafted and implemented the following policy:
Clinical staff will complete treatment plan updates in 15-day increments counting from the date of ATR.
Clinical Director will retrain all applicable staff on policy. Clinical Director will oversee compliance of this policy with weekly chart audits.
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