INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 2022 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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705.28 (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 fire drill records from July, 2021 through April 2022, the facility failed to set off a fire alarm or smoke detector during each fire drill. The facility used a verbal staff announcement.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the July 1, 2021 licensing inspection.
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Plan of Correction
Due to the fire alarm system setting off the alarms for all surrounding businesses, a request for a waiver has been submitted to allow for the use of an alternate way of notifying staff and patients of fire drill. Moving forward, facility director, or assigned designee, that is completing the fire drill will utilize a portable fire alarm to notify all staff and patients of a fire drill taking place.
Facility director and all designees responsible for conducting fire drills have been retrained to ensure they know that the portable fire alarm must be used for each fire drill. Facility director will be checking monthly to ensure that each fire drill is completed correctly. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information in one out of seven records reviewed, as there was a form that was missing required information.Client #2 was admitted on December 17, 2021 and was still active at the time of the inspection. There was a consent to release form, signed and dated on December 17, 2021 to a referral source, but the consent form did not include the purpose of disclosure.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All therapists have been retrained by Clinical Supervisor by 6/3/2022, and will obtain a completed consent form with purpose of disclosure for every individual who comes into our care.
Clinical Supervisor will be completing chart checks weekly moving forward to ensure all consents are completed appropriately. Any consents that are not completed appropriately will be adjusted by their therapist and completed with patient. Clinical Supervisor will be following up with adjusted consents to ensure that they are completed thoroughly.
Treating therapist for client #2 will complete a new release form for this client by including purpose of disclosure and have client # 2 sign within 7 days of this POC, 6/10/2022. Clinical Supervisor will be checking on 6/10/2022 to ensure that this consent is completed.
Moving forward, Clinical Supervisor will discuss and provide training as needed for the release of information procedure and documenting purpose of disclosure during weekly staff meetings. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include case consultations every ninety days, in one out of two applicable records. Client #4 was admitted on January 4, 2022 and was still active at the time of the inspection. A case consultation was due no later than April 4, 2022. There was no case consultation in the file at the time of the inspection.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor has informed and re-trained all therapists to complete all client records, which will include a case consultation, for every individual who comes into our care.
Clinical Supervisor will verify this procedure is being completed appropriately with weekly chart checks, and will verify that case consultations forms are completed correctly and timely every 90 days for each individual in our care.
Treating therapist for client #4 has been informed, and will complete a case consultation for client # 4 within 7 days of this POC, 6/10/2022. Clinical Supervisor will be checking patient's chart on 6/10/2022 to ensure that this is completed.
Moving forward, Clinical Supervisor will discuss and provide training as needed for completing case consultations every 90 days for each individual in our care during weekly staff meetings. |