INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Little Creek Lodge, 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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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in three of seven client records reviewed. Client # 5 was admitted on March 3, 2024 and was discharged on March 30, 2024. The release of information forms to a laboratory, the funding source, a hospital, a parent, a sponsor, a medical group, and an employer were all signed by the client throughout the treatment episode; however, there was no documentation that a copy of any of the consent forms were offered to the client. Client # 6 was admitted on February 18, 2024 and was discharged on March 19, 2024. The release of information forms to a funding source, a volunteer organization, a hospital, an outside recovery house, a laboratory, a doctor, an emergency contact, and a parent were all signed by the client on February 18, 2024; however, there was no documentation that a copy of any of the consent forms were offered to the client. Client # 7 was admitted on February 5, 2024 and was discharged on March 6, 2024. The release of information forms to a laboratory, a funding source, a hospital, an emergency contact, a primary care physician, a psychiatrist, and a pharmacy were all signed by the client throughout the treatment episode; however, there was no documentation that a copy of any of the consent forms were offered to the client. This is a repeat citation from the September 12, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/28/2024, it is now automatic that the ROI form cannot be completely processed in our EMR without a copy of the form being offered to the client. This is a required box that must be selected in order for the form to be signed off on and completed in the system. |
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 a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is also to include the reason for termination, in one of one applicable client record reviewed.Client # 4 was admitted on March 9, 2024 and was administratively discharged on March 15, 2024. There was no documentation in the record indicating the client was notified in writing of the facility's decision to involuntarily terminate the client from treatment. This is a repeat citation from the September 12, 2024 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During a weekly Clinical Team Meeting on 8/26/24, a review of the Administrative Discharge process was reviewed with the entire clinical team by the Clinical Director. Specifically, the protocol of needing to notify clients of the reason for their termination from treatment in writing prior to their termination, was reviewed. Additionally, the need to demonstrate that this notification has been mailed home if the client refuses to sign off on being informed of this, was reviewed. All non-routine discharges will be audited within 72 hours by the Clinical Director for the next 6 months to make sure all documentation and processes are being handled properly. |