INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 2023 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 #12, who was hired as a counselor on May 23, 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 required to be a counselor with a bachelor's degree.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 12, 2021 and May 17, 2022 licensing inspections.
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Plan of Correction
By 7/3/2023, the Vice President of Quality and Regulatory Affairs will work with Executive Director to outline qualifications per the staffing regulations for DDAP to ensure that all applicants for counselors meet qualifications. Moving forward, Human Resources manager and Executive Director will review all applicants to ensure that they are appropriate for positions prior to moving forward with the hiring process. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #10 was hired on June 25, 2022 as a counselor and was still in the position as of the date of the inspection. The training was completed on July 11, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Human Resources representative at site will continue to review the safety orientation with each new hire during the biweekly new hire orientation. Human Resources representative at site will ensure that all employee safety orientation, which includes instructing the staff on how to use the fire extinguishers, is completed prior to each employee working their first shift.
If we need to start someone prior to the biweekly new hire orientation, Human Resources representative will meet with individual prior to them starting their first shift. Human Resources Director will oversee the process and ensure implementation by 7/3/2023. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #10 was hired on June 25, 2022 as a counselor and was still in the position as of the date of the inspection. The training was completed on July 11, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Human Resources representative at site will continue to review the safety orientation with each new hire during the biweekly new hire orientation. Human Resources representative at site will ensure that all employee safety orientation, which includes instructing the staff on how to perform assigned task during emergencies, is completed prior to each employee working their first shift.
If we need to start someone prior to the biweekly new hire orientation, Human Resources representative will meet with individual prior to them starting their first shift. Human Resources Director will oversee the process and ensure implementation by 7/3/2023. |
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
Based on a review of fire drill logs from May 19, 2022 through April 24, 2023 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. No sleeping drills were completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will be conducting a 3am fire drill during September 2023 and March 2024. Moving forward, Executive Director will oversee this process to ensure that there are fire drills taking place overnight at least every 6 months. |
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 a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in one out of ten records reviewed.
Client #1 was admitted on April 24, 2023 and was still active at the time of the inspection. A consent form dated April 26, 2023 to a family member did not list the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 7/3/2023, Director of Quality Assurance will retrain applicable staff on how to appropriately input the purpose of disclosure on each consent. 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 re-signed by patient. Director of Quality Assurance will continue re-train applicable staff members 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 the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.
Client #7 was admitted on April 14, 2023 and discharged on April 24, 2023.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 17, 2022 licensing inspection.
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Plan of Correction
By 7/3/2023, Shift Administrator will be responsible for sending out a letter in the mail, notifying the patient the facility's decision to involuntarily terminate the patient's treatment, to each involuntarily discharged patient. Shift Administrator will also be responsible for uploading each letter into patient charts, confirming that this letter was sent to the discharged patient. Clinical Director and Executive Director will be reviewing all involuntary discharges on a monthly basis to ensure ongoing compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of staff training records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for qualifications for the position of counselor were submitted and approved by the Department for the October 12, 2021 and May 17, 2022 annual licensing inspections. Qualifications for the position of counselor was again found to be a deficiency in the May 17, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/3/2023, the Vice President of Quality and Regulatory Affairs will work with Executive Director to outline qualifications per the staffing regulations for DDAP to ensure that all applicants for counselors meet qualifications. Moving forward, Human Resources manager and Executive Director will review all applicants to ensure that they are appropriate for positions prior to moving forward with the hiring process. |