INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from May, 2023 through March, 2024 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on September 27, 2023 and the next one was due no later than March, 2024. No sleep drill was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Safety Director will ensure that overnight fire drills are conducted every 5 months moving forward. As of May 1st, 2024, we have overnight fire drills scheduled to take place in May 2024, October 2024, and March 2025. Safety Director will be responsible for ensuring overnight fire drills are scheduled after that. Executive Director will oversee Safety Director and ensure that these are being completed. These fire drills will be marked within our monthly fire drill form, and also discussed in our monthly safety committee meeting. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of detox client records, the facility failed to notify the emergency contact of the client leaving the facility against medical advice.
Client #5 was admitted on November 1, 2023 and discharged on November 7, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will conduct a training on unplanned discharges and the protocols associated with them for all clinical supervisors and shift administrators by June 15th, 2024. Clinical Director will apply direct focus in the training on Contacting the emergency contact when a patient leaves AMA. Clinical Director will be responsible for ensuring all clinical supervisors and shift administrators receive this training moving forward. Clinical Director will also be responsible for overseeing all chart checks on a weekly basis to ensure that this is being noted upon AMA discharge. |
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 inpatient client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.
Client #13 was admitted on November 26, 2023 and discharged on November 28, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Shift Administrator will be responsible for sending out a letter in the mail, notifying the patient the facility's decision to involuntarily terminate the patient's treatment, to each involuntarily discharged patient. Shift Administrator will also be responsible for uploading each letter into patient charts, confirming that this letter was sent to the discharged patient. Once this letter is uploaded into the patient chart, the patient is able to view it within the patient portal, ensuring it is received by the patient in some way. Clinical Director and Executive Director will be reviewing all involuntary discharges on a monthly basis to ensure ongoing 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 a review of inpatient client records, the facility failed to document proposed type of support service on individual treatment plans in six out of six applicable records reviewed.
Client #8 was admitted on March 29, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was dated March 29, 2024.
Client #9 was admitted on March 20, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was dated March 20, 2024.
Client #10 was admitted on March 15, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was dated March 18, 2024.
Client #11 was admitted on March 12, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was dated March 13, 2024.
Client #12 was admitted on March 8, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was dated March 8, 2024.
Client #14 was admitted on December 20, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was dated January 4, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will be responsible for training all qualified counselors on thorough documentation within treatment plans, including documenting proposed type of support service. Clinical Director will have all counselors trained by June 15th, 2024. Clinical Director will be responsible for ensuring all counselors are trained moving forward and will also be responsible for overseeing chart checks on a weekly basis to ensure that this is being completed. |