INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted on July 2, 2021 through July 7, 2021 from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the off-site complain investigation, Retreat of 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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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 documents and staff interviews, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project.These findings were reviewed with project staff during the complaint investigation.
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Plan of Correction
Moving forward for any involuntary discharges, the reason and decision for any involuntary discharge will be noted in the discharge summary. The discharge summary will be provided to the patient by the Clinical Supervisor and/or Shift Administrator on duty. |
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 the review of client documents and staff interviews, the project failed to allow the client an opportunity to request reconsideration of a decision terminating treatment.These findings were reviewed with project staff during the complaint investigation.
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Plan of Correction
Patients will be informed by the Clinical Director or Administrator on duty or designee of appeal process for discharge, should they want to appeal. All patients will be able to ask for reconsideration of involuntary discharge. Involuntary Discharge policy has been revised to reflect steps to take during an involuntary discharge and the steps to be given to the patient for appeal process. Policy will be issued and reviewed with all clinical staff by the Clinical Director to ensure that involuntary discharge process is fully understood. |