INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2021 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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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical site inspection on June 30, 2021, the facility failed to ensure that each bathroom had individual paper towels or a mechanical dryer.The ladies ' bathroom did not have paper towels or a mechanical dryer. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Paper towels have been placed in each of the restrooms throughout the facility. Staff will regularly inspect the restrooms to ensure there are paper towels stocked at all times. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill log on June 30, 2021, the facility failed to set off a fire alarm or smoke detector during each of the seven fire drills reviewed. The facility used a verbal staff announcement to conduct monthly fire drills from November 2020 through May 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will conduct full fire drills as required, utilizing the fire alarm or smoke detector for each fire drill going forward. Staff will no longer conduct fire drills by verbal staff announcement.
Facility director or assigned designee will be completing each fire drill. Each person responsible for fire drills has been retrained to ensure they know that a smoke detector or fire alarm needs to be used. Facility director will be checking monthly to ensure that each fire drill is completed correctly based off the requirements. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records on June 30, 2021, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The project failed to obtain a client signature in one out of seven records. Client # 4 was admitted on April 1, 2021 and was active at the time of the inspection. Consents to release information to a health insurance provider, probation, a primary care physician and an emergency contact all dated April 1, 2021 did not have a client signature. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Staff will obtain informed and voluntary consent for all clients, including signatures for each consent form. To ensure compliance, charts will be reviewed regularly by facility director or designee for the appropriate, completed consent forms for each client. Any consent forms found during chart checks that are not completed correctly will be fixed by the facility director or designee and resigned by the patient immediately. |