INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the 30-day regulatory period as required by Chapter 709 in two of five client records reviewed.
The findings include:
Five client records requiring documentation of treatment plan updates within the regulatory timeframe were reviewed on February 18, 2016. The facility failed to document treatment plan updates within the 30-day timeframe in client records, #1 and 6.
Client #1 was admitted into treatment on January 7, 2016 and was still an active client as of the date of the on-site inspection. The master treatment plan was completed on 01/07/2016 and the next treatment plan update was to be completed by 02/07/2016. However, the treatment plan update was not completed until 02/12/2015, which is outside of the 30-day regulatory timeframe.
Client #6 was admitted into treatment on November 2, 2015 and was discharged on December 14, 2015. The master treatment plan was completed on 11/04/2015 and the next treatment plan update was to be completed by 12/04/2015. However, there was not a treatment plan update documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will devise a tracking system utilizing a calendar and scheduler system within the electronic medical record system to have alerts for the therapist to update treatment plans within the proper time frames. Clinical supervisor will train the therapist on this system and will ensure maintenance of this system and timely treatment plan updates via weekly chart checks and weekly supervision staff meetings. This will be under the leadership of the OP Director. |
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 provide documentation that the individual treatment and rehabilitation plan was developed with the client in four of seven client records reviewed.
The findings include:
Seven client records requiring the documentation of the client-involved development of the individual treatment and rehabilitation plan were reviewed on February 18, 2016. The individual treatment and rehabilitation plans in client records, #4, 8, 9 and 10 did not include verification that the client had provided input when the treatment plan was developed.
Client #4 was admitted into treatment on April 10, 2015 and was still an active client at the time of the licensing inspection. The individual treatment and rehabilitation plan was developed on 04/10/2015, but did not include the client signature indicating the plan was developed with input from the client.
Client #8 was admitted into treatment on June 19, 2015 and was discharged on August 27, 2015. The individual treatment and rehabilitation plan was developed on 06/19/2015, but did not include the client signature indicating the plan was developed with input from the client.
Client #9 was admitted into treatment on August 12, 2015 and was discharged on December 18, 2015. The individual treatment and rehabilitation plan was developed and signed by the counselor on 08/13/2015, but the client did not sign and date the treatment plan until 08/20/2015.
Client #10 was admitted into treatment on July 8, 2015 and was discharged on November 11, 2015. The individual treatment and rehabilitation plan was developed and signed by the counselor on 07/23/2015, but the client did not sign and date the treatment plan until 08/10/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will meet with the therapists to review the guidelines of therapists developing the treatment plan with the client and will monitor this is occurring via weekly chart checks and supervision meetings under the leadership of the Outpatient Director. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the 60-day regulatory period as required by Chapter 709 in four of seven client records reviewed.
The findings include:
Seven client records requiring documentation of treatment plan updates within the regulatory timeframe were reviewed on February 18, 2016. The facility failed to document treatment plan updates within the 60-day timeframe in client record #'s 3, 4, 5, 9, and 10.
Client #3 was admitted into treatment on September 14, 2015 and was still an active client as of the date of the on-site inspection. A treatment plan update was completed on 11/30/2015 and the next treatment plan update was due to be completed on 01/30/2016, however, there was no treatment plan update completed at the time of the inspection.
Client #4 was admitted into treatment on April 10, 2015 and was still an active client as of the date of the on-site inspection. A treatment plan update was completed on 09/24/2015 and the next treatment plan was to be completed by 11/24/2015. However, the treatment plan update was not completed until 12/15/2015, which is outside of the 60-day regulatory timeframe.
Client #5 was admitted into treatment on July 17, 2015 and was discharged on January 15, 2016. A treatment plan update was completed on 10/08/2015 and the next treatment plan was to be completed by 12/08/2015. However, the treatment plan update was not completed until 12/28/2015, which is outside the 60-day regulatory timeframe.
Client #9 was admitted into treatment on August 12, 2015 and was discharged on December 18, 2015. A treatment plan update was completed on 10/03/2015 and the next treatment plan was to be completed by 12/03/2015. However, there was not a treatment plan update documented in the client record at the time of the inspection.
Client #10 was admitted into treatment on July 8, 2015 and was discharged on November 11, 2015. A treatment plan update was completed on 08/20/2015 and the next treatment plan was to be completed by 10/20/2015. However, there was not a treatment plan update documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will devise a tracking system utilizing a calendar and scheduler system within the electronic medical record system to have alerts for the therapist to update treatment plans within the proper time frames. Clinical supervisor will train the therapist on this system and will ensure maintenance of this system and timely treatment plan updates via weekly chart checks and weekly supervision staff meetings. This will be under the leadership of the OP Director. |