INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2018 through August 24, 2018 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 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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705.4 (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
The facility failed to ensure privacy of counseling sessions as counseling room S154 had no window coverings, allowing counseling session to be seen from outside the room. Additionally, a counseling session was overheard while standing outside counseling room S153.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A sound machine was placed in the counselor office where the sound was being heard. A set of blinds was hung in the window of the said therapist's office for privacy.
Weekly facility walk through will be conducted for ongoing compliance by the chief clinical officer.
In addition the clinical staff were made aware to stay compliant with this regulation.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The facility failed to ensure that the men's bathroom, located in the gym, was properly ventilated by an exhaust fan or operable window. The exhaust fan was inoperable and the bathroom did not have a window.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The said exhaust fan was fixed and is now operable.
Weekly walk through will be completed by the facilities director to ensure compliance so that all exhaust fans are operable.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project director verbally confirmed that no annual financial audit was conducted for the preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The annual audit is being conducted currently and will be complete by the end of this month. This will be monitored by the Chief Financial Officer.
The CFO will ensure compliance via annual reviews. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to include documentation verifying the written acknowledgement by clients that they had been informed of their right to appeal a decision limiting access to their records to the director, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records and the right to submit rebuttal data or memoranda to their own records, in every client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The bill of rights has been updated to reflect that they had been informed of their right to appeal a decision limiting access to their records to the director, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records and the right to submit rebuttal data or memoranda to their own records, in every client record reviewed. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The facility failed to document that work done by the client at the project was an integral part of the treatment and rehabilitation plan in seven of seven applicable records reviewed.
Client #9 was admitted on July 24, 2018 and was discharged on August 1, 2018.
Client #10 was admitted on April 12, 2018 and was discharged on May 7, 2018.
Client #11 was admitted on April 10, 2018 and was discharged on May 3, 2018.
Client #12 was admitted on July 31, 3018 and was discharged on August 15, 2018
Client #13 was admitted on April 24, 2018 and was discharged on May 10, 2018.
Client #14 was admitted on May 5, 2018 and was active at the time of the inspection.
Client #15 was admitted on August 8, 2018 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patients's treatment plans will reflect that there are work as part of their rehab plans. The primary counselors are trained in this. This will be monitored by the Clinical Supervisors via weekly chart checks. |