INITIAL COMMENTS
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This report is a result of an on-site inspection to this newly licensed facility following the admittance of its first client. The inspection was conducted on December 8, 2011 and December 9, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of this on-site inspection, 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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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills, as required by regulation.
The findings include:
The fire drill records were reviewed on December 9, 2011. Fire drill records were reviewed for the months of September 2011, October 2011, and November 2011. The facility failed to document that any exits were blocked during the drill. It appeared that all exits were used for each drill.
The facility/project director was interviewed and confirmed this finding.
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Plan of Correction
Safety Director was informed by Executive Director that there must be documentation of a blocked exit for each fire drill. Executive Director will monitor to ensure this happens in all future fire drills. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on the review of administrative documentation, the facility failed to obtain written letters of agreement or understanding with primary referral sources, as required.
The findings include:
The project/facility director was requested to provide documentation of written letters of agreement or understanding with primary referral sources. The project/facility director was interviewed on December 8, 2011 at 1:00 p.m. and stated that she had not obtained any to date.
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Plan of Correction
Referral agreements have been mailed out to primary referral sources. They will be logged in and kept in a binder. Executive Director will monitor to ensure they are kept current. |
709.26(a)(12) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(12) Employe grievances.
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Observations
Based on the review of the facility's policy and procedures, the facility failed to include what an employee should do if they had a grievance against the project/facility director.
The findings include:
The facility's policy and procedure manuals was reviewed December 8, 2011. The facility's policy on handling employee grievances was reviewed. The policy failed to include what steps an employee should follow if they had a grievance against the project/facility director and who would be responsible for addressing the grievance.
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Plan of Correction
Policy has been updated to ensure that there is a plan for the facility director in case of a grievance followed. The owner will be the contact person in such cases and be involved in the resolution process. Owner and Facility Director are both aware of this policy. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in one of six records. Additionally, one of six records also exceeded 4 Pa. Code, Subsection 255.5(b).
The findings include:
Six client records were reviewed on December 9, 2011. All client records were required to include an informed and voluntary consent from the client prior to the disclosure of information. Patient record # 1 failed to have a consent signed by the client for the funding source. Documentation was included in the record for the release of information to the client's insurance company. Additionally, patient record # 2 had a consent to release form for the funding source that exceeded 4 Pa. Code, Subsection 255.5(b). The consent to release allowed for the release of the discharge summary, aftercare treatment plan, history and physical, consultations, face sheet, and lab reports.
A discussion with the facility/project director confirmed this finding.
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Plan of Correction
An in-service was provided to all staff members re-iterating the terms of the release forms and what is able to be released based on the Confidentality laws. Executive Director will monitor patient records to ensure there are no excess information released at any time. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of the facility's policy and procedures, the facility failed to document a psychosocial evaluation within the required timeframe.
The findings include:
The facility's policy and procedures were reviewed on December 8, 2011. According to the facility's policy, a counselor will complete a clinical summary (Psychosocial Evaluation) within five days of admission. Six client records were reviewed on December 9, 2011. One record was reviewed for services obtained from the inpatient short-term detoxification activity of the project. The facility failed to document a timely clinical summary in patient record # 4.
Patient # 4 was admitted into the detoxification program on November 7, 2011 and discharged on November 14, 2011. The clinical formulation (Psychosocial Evaluation) was due by November 12, 2011. The clinical formulation was documented on November 16, 2011. This was four days late and completed after the client was discharged.
A discussion with the project/facility director confirmed this finding.
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Plan of Correction
All patient records will be monitored to ensure that evaluations are completed in a timely fashion. This will be monitored by Clinical Supervisor and Executive Director. All clinical staff were informed of this regulation and told they would be monitored closely. Weekly chart reviews by Clinical Supervisor under direction of Executive Director will ensure compliance with this regulation. |
715.3(a)-(h) LICENSURE Approval of narcotic treatment programs
(a) An entity shall apply for and receive approval as required from the Department, DEA and CSAT or an organization designated by the Substance Abuse and Mental Health Services Administration (SAMHSA), under the authority of section 303 of the Controlled Substances Act (21 U.S.C.A. § 823) and sections 501(d), 509(a), 543, 1923, 1927(a) and 1976 of the Public Health Service Act (42 U.S.C.A. §§ 290aa(d), 290bb-2(a), 290dd-2, 300x-23, 300x-27(a) and 300y-11), prior to offering services within this Commonwealth as a narcotic treatment program. Application for approval shall be made simultaneously to the Department, DEA and CSAT or SAMHSA designee.
(1) The Department will forward a recommendation for approval to the Federal officials after a review of policies and procedures and an onsite inspection by an authorized representative of the Department and after a determination has been made that the requirements for approval under this chapter have been met.
(2) The decision of the Federal officials set forth in 21 CFR Chapter II (relating to Drug Enforcement Administration, Department of Justice) or other Federal statutes shall constitute the final determination on the application for approval by DEA and CSAT or SAMHSA designee.
(b) A narcotic treatment program shall be licensed under the Department's regulations for drug and alcohol facilities in Chapter 157, 704, 705, 709 or 711. When a licensee applies to operate a narcotic treatment program, the history component of the application of the licensee shall include the licensee's record of operation of any facility regulated by any State or Federal entity. A narcotic treatment program may not be recommended for approval unless licensure has been obtained under Chapters 157, 704, 705, 709 or 711.
(c) The Department will grant approval as a narcotic treatment program after an onsite inspection and review of narcotic treatment program policies, procedures and other material, when the Department determines that the requirements for approval have been met.
(d) The Department will inspect a narcotic treatment program at least annually to determine compliance with State narcotic treatment program regulations. This inspection shall consist of an onsite visit and shall include an examination of patient records, reports, files, policies and procedures, and other similar items to enable the Department to make an evaluation of the status of the narcotic treatment program. The Department may inspect the narcotic treatment program without notice during any regular business hours of the narcotic treatment program.
(e) During the inspection process, a narcotic treatment program shall make available to the authorized staff of the Department full and free access to its premises, facilities, records, reports, files and other similar items necessary for a full and complete evaluation. The Department may make copies of materials it deems necessary under 42 CFR 2.53 (relating to audit and evaluation activities) and §§ 709.15 and 711.15 (relating to right to enter and inspect; and right to enter and inspect).
(f) The authorized Department representative may interview patients and staff as part of the inspection process.
(g) The Department may grant approval as a narcotic treatment program after an onsite inspection when the Department determines that a narcotic treatment program satisfies the following:
(1) It has substantially complied with applicable requirements for approval.
(2) It is complying with a plan of correction approved by the Department with regard to any outstanding deficiencies.
(3) Its existing deficiencies will not adversely alter the health, welfare or safety of the facility 's patients.
(h) Notification of deficiencies involves the following:
(1) The authorized Department representative will provide the program director with a record of deficiencies with instructions to submit a plan of correction.
(2) The narcotic treatment program shall complete the plan of correction and submit it to the Department within 21 days after the last day of the onsite inspection.
(3) The Department will not grant approval as narcotic treatment program until the Department receives and approves a plan of correction.
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Observations
Based on observation during the physical plant inspection and review of client records, it was determined the facility is using a narcotic, specifically Subutex, without the approval of the Department, as required.
The findings include:
The physical plant inspection took place on December 8, 2011 between the hours of 2:30 p.m. and 3:40 p.m. Two nursing stations were inspected and the contents of the medication cart were reviewed. The facility had stock narcotics, specifically Subutex, to be used in the detoxification process. It was also observed in client record # 2, that she was prescribed Subutex as needed for withdrawal symptoms. The facility failed to have approval from the Department for the use of Subutex.
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Plan of Correction
Policies and procedures were submitted for approval for use of Buprenorphine in August of 2011. However, the facility used Buprenorphine without prior approval. Policies and procedures were submitted in August of 2011. Follow up by Executive Director was done with DOH in September, December, January and February. Until the certificate of approval is issued, the Executive Director will ensure that Buprenorphine is not used. The Executive Director understands that the deficiency was issued due to the fact that the facility uses Buprenorphine without approval from the Department of Health. The Executive Director will also ensure that the areas of noncompliance will remain rectified and current. The Executive Director understands that this type of services is not to be used until the DOH approves it. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document a physical examination in one of three records.
The findings include:
Six patient records were reviewed on December 9, 2011. Three client records were from the inpatient non-hospital residential program. According to the facility's policy and procedures, the facility will document a physical examination within four days of admission. The facility failed to document a history and physical in one of three records reviewed, specifically record # 2.
Client # 2 was admitted on October 18, 2011 and discharged on November 17, 2011. According to the facility's policy, a physical examination was due by October 22, 2011. The facility did not provide documentation of a physical examination in this client record at there time of the inspection.
This was reviewed with the project/facility director and the finding was confirmed.
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Plan of Correction
Executive Director reviewed with Medical Director these findings. H&P will be completed in a timely manner and Executive Director will monitor via chart checks daily. A reminder will be sent to Medical Director if not done close to time frame alloted. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in two of three client records.
The findings include:
Six client records were reviewed on December 9, 2011. Preliminary treatment and rehabilitation plans were required in three client records in the inpatient non-hospital residential program. According to the facility's policy and procedure manual, preliminary treatment plans will be documented within two days of admission. The facility failed to document preliminary treatment and rehabilitation plans in client records #1 and 2.
Client # 1 was admitted on October 7, 2011 and discharged on October 28, 2011. The facility did not document a preliminary treatment plan in the client record.
Client # 2 was admitted on October 18, 2011 and discharged on November 17, 2011. The facility did not document a preliminary treatment plan in the client record.
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Plan of Correction
all clinical staff were informed that preliminary treatment plans must be completed in alloted time frame. This will be monitored via daily chart checks by Clinical Supervisor under direction of Executive Director. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on review of client records, the facility failed to document short and long-term treatment goals in two of three records reviewed.
The findings include:
Six client records were reviewed on December 9, 2011. Three records were from the inpatient non-hospital residential program. The facility failed to document short and long-term goals in the individual treatment plan that was developed with the client in records # 1 and 3.
Client # 1 was admitted on October 7, 2011. An individual treatment and rehabilitation plan was developed on October 12, 2011. The facility failed to include long-term goals in the treatment and rehabilitation plan.
Client # 3 was admitted on October 11, 2011. An individual treatment and rehabilitation plan was documented; however, the plan was not dated or signed by the client. The treatment and rehabilitation plan did not include long-term goals.
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Plan of Correction
All clinical staff were informed of the need for short and long term goals for all treatment plans. Treatment plans will be modified to ensure they are included in all treatment plans. This will be monitored via chart checks by Clinical Supervisor under direction of Executive Director |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of services in the individual treatment and rehabilitation plan in three of three client records.
The findings include:
Six client records were reviewed on December 9, 2011. The type and frequency of services were required in the individual treatment and rehabilitation plan in three client records. The facility did not document the type and frequency of services in the individual treatment and rehabilitation plan in client records # 1, 2, and 3.
This was discussed with the project/facility director and she confirmed this finding.
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Plan of Correction
Treatment plans will be modified to include services provided including type and frequency. Clinical staff will be informed of this modification. Chart checks will be conducted by Clinical Supervisor under direction of Executive Director to ensure compliance . |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in the individual treatment and rehabilitation plan in two of three client records.
The findings include:
Six client records were reviewed on December 9, 2011. Support services were required in the individual treatment and rehabilitation plan three client records. The facility did not document support services on the individual treatment and rehabilitation plan in client records # 1 and 3.
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Plan of Correction
Support services will be added to treatment plans in the electronic medical record system. Chart checks will be conducted to ensure all clinical staff include this. Clinical staff will be informed of this change via training. Chart checks will be completed daily by Clinical Supervisor to ensure compliance under direction of Executive Director |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, there was no way to determine if counseling services were provided according to the individual treatment and rehabilitation plan in three of three records.
The findings include:
Six records were reviewed on December 9, 2011. The treatment plans failed to include the type and frequency of the client's rehabilitation services. Therefore there was no way to determine if the clients were provided services according to their treatment and rehabilitation plan in records # 1, 2, and 3.
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Plan of Correction
Treatment plans will be modified to ensure inclusion of support services, type of treatment services provided and frequency of such services. Clinical staff will be informed of this change and trained on treatment plan documentation to include these services. Daily chart checks will be completed by Clinical Supervisor to ensure compliance under direction of Executive Director |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in one of one client records.
The findings include:
Six client records were reviewed on December 9, 2011. A preliminary treatment and rehabilitation plans was required in one client record from the outpatient program. According to the facility's policy and procedure manual, preliminary treatment plans will be documented within fifteen days of admission. The facility failed to document preliminary treatment and rehabilitation plan in client records # 5.
Client # 5 was admitted on October 24, 2011 and discharged on December 2, 2011. The facility did not document a preliminary treatment plan the client record.
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Plan of Correction
All clinical staff will be trained on treatment planning to include preliminary treatment plans. Treatment plans will be modified to ensure this. Daily chart checks will be conducted by Clinical Supervisor to ensure compliance under direction of Executive Director. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 review of client records, the facility failed to document a treatment and rehabilitation plan that was developed with the client in one of two records.
The findings include:
Six patient records were reviewed on December 9, 2011. Two records were from the outpatient activity from the program and both required an individual treatment and rehabilitation plan that was developed with the client. The facility failed document an individual treatment and rehabilitation plan that was developed with the client in record # 5.
Client # 5 was admitted on October 24, 2011. A treatment and rehabilitation plan was developed; however, there was no documentation that ensured it included client's input. The plan was not signed and dated by the client.
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Plan of Correction
All clinical staff will be informed and trained on ensuring patient signature on all treatment plans to include patient in the development of treatment plans. Chart checks will be conducted to ensure compliance under direction of Executive Director. Chart checks will be done at least 5 times week. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on review of client records, the facility failed to document short and long-term treatment goals in two of two records reviewed.
The findings include:
Six client records were reviewed on December 9, 2011. Two records were from the outpatient program. The facility failed to document short and long-term goals in the individual treatment plan in records # 5 and 6.
Client # 5 was admitted on October 24, 2011. An individual treatment and rehabilitation plan was developed; however, the plan was not dated or signed by the client. The treatment and rehabilitation plan did not include short-term goals.
Client # 6 was admitted on November 28, 2011. An individual treatment and rehabilitation plan was documented on December 8, 2011. The treatment and rehabilitation plan did not include short-term goals.
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Plan of Correction
All treatment plans will include short and long term goals and will be modified accordingly in the electronic medical record system. All clinical staff will be informed and trained to carry out accordingly. Daily chart checks will be conducted by Clinical Supervisor under direction of Executive Director to ensure compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of services in the individual treatment and rehabilitation plan in two of two client records.
The findings include:
Six client records were reviewed on December 9, 2011. The type and frequency of services were required in the individual treatment and rehabilitation plan in two client records from the outpatient program. The facility did not document the type and frequency of services in the individual treatment and rehabilitation plan in client records # 5 and 6.
This was discussed with the project/facility director and she confirmed this finding.
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Plan of Correction
All treatment plans in electronic medical record system will be modified to ensure inclusion of type and frequency of services for all patient records. All clinical staff will be informed and trained on this process. Chart checks by Clinical Supervisor under direction of Executive Director will ensure compliance with this. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in the individual treatment and rehabilitation plan in two of two client records.
The findings include:
Six client records were reviewed on December 9, 2011. Support services were required in the individual treatment and rehabilitation plan two client records from the outpatient program. The facility did not document support services on the individual treatment and rehabilitation plan in client records # 5 and 6.
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Plan of Correction
Treatment plans will be modified in electronic medical record system to ensure support services are included. All clinical staff will be informed and trained on this procss. Chart checks daily will be conducted to ensure compliance by Clinical Supervisor under direction of Executive Director. |