INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. Part 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. Part 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on December 9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Retreat at Lancaster County, 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:
|
Plan of Correction
|
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
|
Observations
Based on a physical plant inspection, the facility failed to keep the couch on the third-floor lounge area in good repair. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Maintenance department has been notified by the Chief Clinical Officer of the damaged couch on the third-floor lounge area. A new couch has been ordered. Maintenance department will replace the damaged couch with the new one on 3/16/2021. Chief Clinical Officer will be following up on 3/16/2021 to ensure that the couch has been replaced. |
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.
|
Observations
Based on a physical plant inspection the facility failed to ensure privacy during counseling sessions as the music group room door had an uncovered window and group could be seen from the hallway.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Music therapist has been notified by the Chief Clinical Officer of the regulation regarding privacy of counseling sessions and steps that need to be taken. Music therapist will have the window to the music room group door covered by 3/5/2021 to ensure that groups cannot be seen from the hallway. Chief Clinical Officer will be following up on 3/5/2021 to ensure that the window to the door has been covered. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of fourteen client records, the facility failed to keep consent to release forms to funding source within limits set forth by 255.5 in all fourteen records by allowing for the release of history and physical, biopsychosocial, treatment plans, type and frequency, discharge summary and provider notes. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
All individuals trained on completing consent to release forms with the patients will retrained by 3/16/2021 on the consent to release form for the funding source. Training will be completed by the Chief Clinical Officer, to ensure that they are not allowing release for history and physical, biopsychosocial, treatment plans, type and frequency, discharge summary and provider notes. Charts checks are completed daily by the Clinical Supervisor to ensure that all consents are completed properly. If any consent is not completed properly, it will be adjusted by the Clinical Supervisor and signed by the patient. |