INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and the inspection for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction, which was conducted on May 17, 2017 through May 19, 2017 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, Retreat at Lancaster County PA, LLC was found to 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
Based on a review of the fire drill records, the facility last conducted fire drills during sleeping hours in January 2016 and November 2016 and no more prior to the date of the inspection; thus, failing to conduct a fire drill during sleeping hours at least one time every 6 months.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Chief Clinical Officer reviewed with the Safety Director the importance of ensuring that the fire drills are completed within 6 months of each other during sleeping hours. The Safety Director understood and will comply. The Chief Clinical Officer will ensure compliance with a monthly review of each fire drill and will assist in the planning of future fire drills. |
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.
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Observations
Based on a review of 22 client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 4 records. Additionally, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 record and a consent to release information form was missing the specific information to be disclosed in 1 record.
Client # 3 was admitted on 6/20/16 and was discharged 6/26/16. A consent to release form was signed and dated on 6/20/16 to the funding source that exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, aftercare, treatment plans, prescriptions, histories and physicals, consultations, lab reports and EKGs.
Client #10 was admitted on 6/26/16 and was discharged 7/18/16. A consent to release form was signed and dated on 6/20/16 to the funding source that exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, aftercare, treatment plans, prescriptions, histories and physicals, consultations, lab reports and EKGs.
Client # 13 was admitted on 05/30/16 and was discharged on 6/4/16. A consent to release form was signed and dated on 5/30/16 to the funding source that exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, aftercare, treatment plans, histories and physicals, consultations, lab reports and EKGs.
Client # 17 was admitted on 6/4/2016 and was discharged on 6/4/16. A consent to release form was signed and dated on 5/30/16 to the funding source that exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, aftercare, treatment plans, histories and physicals, consultations, lab reports and EKGs.
Client # 18 was admitted on 12/2/16 and was discharged on 12/27/16. A consent to release information form was signed and dated on 12/16/16 to a legal entity, however, the form did not include the specific information to be disclosed.
Client # 20 was admitted on 4/24/17 and was an active client at the time of the inspection. There was documentation that the facility billed the funding source; however, there was no consent to release information form signed by the client prior to the disclosure of information.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pertinent staff members that generate consent forms - Clinical and Intake staff - will attend a training with regard to the PA Code 255.5 and will demonstrate understanding that consent to disclose cannot exceed the parameters. This will be done under the direction of the Chief Clinical Officer and will be monitored for compliance via weekly chart checks. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the facility's unusual incident reports on May 17-19, 2017, the facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.
The incident dates and reasons are:
August 11, 2016 - Ambulance presence requested
August 14, 2016 - Ambulance presence requested
August 22, 2016 - Ambulance presence requested
November 1, 2016 - Ambulance presence requested
November 16, 2016 - Ambulance presence requested
December 25, 2016 - Ambulance presence requested
January 10, 2017 - Ambulance presence requested
February 14, 2017 - Ambulance presence requested
March 22, 2017 - Ambulance presence requested
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Chief Clinical Officer will review all incident reports on a daily basis and will ensure they are faxed to DDAP as appropriate based on the unusual incident. The CCO will monitor this on a daily basis. |