INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 6, 2015 by staff from the Division of Drug and Alcohol 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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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to document the type and frequency of treatment services on the individual treatment and rehabilitation plan in three of seven partial hospitalization client records reviewed.
The findings include:
Seven partial hospitalization client records requiring documentation of the type and frequency of treatment services on the individual treatment and rehabilitation plans were reviewed during the renewal inspection on 4/6/2015. The individual treatment and rehabilitation plans contained in client records # 1, 4 and 8 did not include the type and frequency of treatment services.
Client # 1 was admitted to partial hospitalization treatment on 11/17/2014. The client's individual treatment and rehabilitation plan initiated on 12/18/2014 did not specify the type and frequency of individual and group counseling therapy.
Client # 4 was admitted to partial hospitalization treatment on 9/23/2014. The client's individual treatment and rehabilitation plan initiated on 10/22/2014 did not specify the type and frequency of individual and group counseling therapy.
Client # 8 was admitted to partial hospitalization treatment on 2/12/2015. The client's individual treatment and rehabilitation plan initiated on 3/13/2015 did not specify the type and frequency of individual and group counseling therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans will be modified to ensure the inclusion of treatment services, frequency and type by May 5. Each therapist will be trained on this process on Friday May 1 at their case conference meeting. This will be monitored by Director of Outpatient via chart checks and individual supervision meetings on a weekly basis. When the treatment plan is modified in the EMR, it will have the information required on each treatment plan automatically. |
709.82(d) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
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Observations
Based on the review of client records, the facility failed to ensure that individual counseling services were provided at least twice weekly in six of seven partial hospitalization client records reviewed.
The findings include:
Seven partial hospitalization client records were reviewed for counseling services during the renewal inspection on 4/6/2015. The facility failed to ensure that clients received individual counseling services at least twice weekly in client records # 2, 3, 4, 7, 8 and 9.
Client # 2 was admitted to partial hospitalization treatment on 3/23/2015 and transferred to outpatient treatment on 3/31/2015. The client's record did not contain documentation of any individual sessions between 3/23/2015 - 3/31/2015.
Client # 3 was admitted to partial hospitalization treatment on 11/26/2014 and transferred to outpatient treatment on 1/8/2015. The only individual sessions scheduled between 11/26/2014 - 1/8/2015 documented in the client's record were on 12/8/2014 and 12/26/2014.
Client # 4 was admitted to partial hospitalization treatment on 9/23/2014 and transferred to outpatient treatment on 11/21/2014. The only individual sessions scheduled between 9/23/2014 - 11/5/2014 documented in the client's record were on 9/24/2014, 9/26/2014 and 11/5/2014.
Client # 7 was admitted to partial hospitalization treatment on 6/16/2014 and transferred to outpatient treatment on 7/18/2014. The only individual sessions scheduled between 6/16/2014 - 7/18/2014 documented in the client's record were on 6/23/2014 and 7/3/2014.
Client # 8 was admitted to partial hospitalization treatment on 2/12/2015 and transferred to outpatient treatment on 3/16/2015. The only individual sessions scheduled between 2/12/2015 - 3/16/2015 documented in the client's record were on 2/12/2015, 2/20/2015, 3/2/2015 and 3/9/2015.
Client # 9 was admitted to partial hospitalization treatment on 3/11/2015 and was still an active client at the time of inspection. The only individual sessions scheduled between 3/11/2015 - 4/5/2015 documented in the client's record was on 3/13/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each patient in PHP will get 2 individual sessions by Therapist. PHP Therapists were educated on this process as of April 24. This will be monitored by Director of OP via chart checks and supervision meetings on a weekly basis. |
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 a decision to involuntarily terminate the client's treatment at the project in two of two client records.
The findings include:
Two client records requiring written notification to the client of the facility's decision to involuntarily terminate the client's treatment were reviewed on 4/6/2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client records # 2 and 6.
Client # 2 was admitted into partial hospitalization treatment on 3/23/2015 and was involuntarily terminated from the facility on 3/31/2015. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the on-site inspection.
Client # 6 was admitted into outpatient treatment on 9/5/2014 and was involuntarily terminated from the facility on 12/31/2014. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patients have been called with regard to involuntary terminations from the program, Moving forward, letters will be sent to patients that are terminated from program and a copy of the letter will be imaged into the EMR. Director of OP will monitor this process via chart checks and individual meetings on a weekly basis. The letters will be signed by Primary Therapist and sent by the Office Manager of the site. There will be no phone calls used to inform patients of involuntary terminations.
Patient 6 and 2 will be sent a letter on Monday April 27. |
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 a review of client records, the facility failed to document the type and frequency of treatment services on the individual treatment and rehabilitation plan in seven of eight outpatient client records reviewed.
The findings include:
Eight outpatient client records requiring documentation of the type and frequency of treatment services on the individual treatment and rehabilitation plans were reviewed during the renewal inspection on 4/6/2015. The individual treatment and rehabilitation plans contained in client records # 1, 3, 4, 5, 6, 7 and 10 did not include the type and frequency of treatment services.
Client # 1 was admitted to outpatient treatment on 1/5/2015. The client's individual treatment and rehabilitation plans initiated on 2/16/2015 and 3/25/2015 did not specify the type and frequency of individual and group counseling therapy.
Client # 3 was admitted to outpatient treatment on 1/8/2015. The client's individual treatment and rehabilitation plan initiated on 3/11/2015 did not specify the type and frequency of individual and group counseling therapy.
Client # 4 was admitted to outpatient treatment on 11/21/2014. The client's individual treatment and rehabilitation plan initiated on 3/25/2015 did not specify the type and frequency of individual and group counseling therapy.
Client # 5 was admitted to outpatient treatment on 2/11/2015. The client's individual treatment and rehabilitation plan initiated on 3/12/2015 did not specify the type and frequency of individual and group counseling therapy.
Client # 6 was admitted to outpatient treatment on 9/5/2014. The client's individual treatment and rehabilitation plans initiated on 10/17/2014 and 11/26/2014 did not specify the type and frequency of individual and group counseling therapy.
Client # 7 was admitted to outpatient treatment on 7/18/2014. The client's individual treatment and rehabilitation plans initiated on 2/27/2015 and 4/1/2015 did not specify the type and frequency of individual and group counseling therapy.
Client # 10 was admitted to outpatient treatment on 10/7/2014. The client's individual treatment and rehabilitation plans initiated on 2/13/2015 and 3/27/2015 did not specify the type and frequency of individual and group counseling therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans will be modified to ensure the inclusion of treatment services, frequency and type by May 5. Each therapist will be trained on this process on Friday May 1 at their case conference meeting. This will be monitored by Director of Outpatient via chart checks and individual supervision meetings on a weekly basis. When the treatment plan is modified in the EMR, it will have the information required on each treatment plan automatically.
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