INITIAL COMMENTS
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This report is a result of complaint investigation conducted on November 5, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Retreat of Lancaster County, PA, were partially substantiated as the facility 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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709.52(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 document an individual treatment and rehabilitation plan developed with the patient in one of one record.
The findings included:
One patient record was reviewed on November 5, 2012. The facility failed to ensure an individual treatment and rehabilitation plan was developed with the patient # 1.
Patient #1 was admitted on September 11, 2012, and discharged on September 28, 2012.
A master treatment plan for September 11, 2012, through September 25, 2012, did not include the patient's signature. The form stated the "patient signature indicated participation in the treatment planning process including providing input about problem areas, strengths and goals." Additionally, there was no documentation in the patient record that indicated that the patient participated in the development of a treatment plan.
A second master treatment plan for September 26, 2012, through October 10, 2012, did not include the patient's signature. The form stated the "patient signature indicated participation in the treatment planning process including providing input about problem areas, strengths and goals." There was no documentation in the patient record that indicated that the patient participated in the development of a treatment plan.
The findings were reviewed with the executive director and confirmed.
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Plan of Correction
Treatment plans will be signed by patient OR a progress note will be documented that the patient agreed with the treatment plan and given a copy of the treatment plan. All participation in the treatment plan will be documented in progress notes. All clinical staff were informed of this process. This will be monitored via daily chart checks under the guidance of executive director. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of patient records, the facility failed to document information relative to the patient's involvement in one of one record.
The findings included:
One patient record was reviewed on November 5, 2012. The facility failed to ensure the contents of the record included information relative to the patient.
Patient #1 was admitted on September 11, 2012, and discharged on September 28, 2012.
A history and physical documented in the patient record referred to an 18 year old male from Trenton, NJ. The patient is a married female from Pennsylvania.
A group progress note was documented in the patient record for service that occurred on October 11, 2012. The note included the patient name, data of the group topic as the disease concept of addiction, assessment of the patient's emotional/behavioral state as grounded, and the plan of continued group therapy, plan an individual session. The patient was discharged on September 28, 2012.
The findings were reviewed with the executive director and confirmed.
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Plan of Correction
The history and physical was documented incorrectly in the patient record. The HnP was moved to the correct record. Staff were informed of the importance of ensuring the records are accurate and in the right person's record. This will be checked via chart checks daily by the Executive Director.
The group note was incorrectly added. The therapist was informed and told to ensure this does not happen again and to double check when adding group notes. This will be monitored by the clinical supervisor via daily chart checks under guidance of Exec Dir |
709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on a review of the physical plant and a discussion with facility personnel, the facility is operating an unlicensed outpatient treatment activity.
The findings include:
The facility is providing an outpatient treatment activity offsite from the residential campus. The facility does not hold a separate license for outpatient treatment activities off campus from its residential facility.
An interview with the facility executive director on November 5, 2012, confirmed the outpatient services have been occurring offsite since July 2012.
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Plan of Correction
Faciltiy acknowledges services were provided at this site prior to licensure approval from dept. Executive Director responsible for this implementation. Will ensure this does not occur in the future by not providing services without proper licesning beforehand. |