INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2024 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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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 outpatient client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of six applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 7 days following admission. Additionally, the facility failed to develop the plan with the client in two out of six records reviewed.
Client #3 was admitted on July 17, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 18, 2023; however, it was not developed with the client.
Client #4 was admitted on January 29, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 5, 2024; however, it was not completed until February 12, 2024.
Client #6 was admitted on August 10, 2023 and was discharged on October 3, 2023. A comprehensive treatment plan was due no later than August 17, 2024; however, it was not completed until August 18, 2023 and was not completed with the client.
Client #7 was admitted on December 19, 2023 and was discharged on February 22, 2024. A comprehensive treatment plan was due no later than December 26, 2023; however, it was not completed until January 17, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Supervisor will review the policy and procedure that a treatment plan needs to be developed within 7 days of admission and developed with the client, during weekly staff meeting for 1 month. Staff will sign-off that they read and understand this treatment plan policy and procedure, and supervisor will complete weekly chart audits of open and discharged charts to verify that individual treatment plans are developed with the client within 7 days of admission. Supervisor will also revisit this policy and procedure during individual and group supervision at 30, 60, and 90 days with staff and complete a corrective action plan with staff who are not adhering to the policy and procedure of developing an individual treatment plan with the client within 7 days of admission. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of six client records reviewed.
Client #2 was admitted on October 19, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 19, 2023 with no type or frequency identified.
Client #3 was admitted on July 17, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 18, 2023 with no type or frequency identified.
Client #4 was admitted on January 29, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 12, 2024 with no type or frequency identified.
Client #7 was admitted on December 19, 2023 and discharged on February 22, 2024. A comprehensive treatment plan was developed on January 17, 2024 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Supervisor will review the regulatory framework with staff to provide written documentation of type and frequency of treatment and rehabilitation services on individual treatment plans, during weekly staff meeting for 1 month. Staff will sign-off that they understand this regulatory framework, and supervisor will complete weekly chart audits of open and discharged charts to verify that there is written documentation of type and frequency of treatment and rehabilitation services on individual treatment plans. Supervisor will also revisit this regulatory framework at 30, 60, and 90 days with staff and complete a corrective action plan with staff who are not adhering to the policy of documenting type and frequency of treatment and rehabilitation services on individual treatment plans. Supervisor will follow-up this corrective action plan with further weekly chart audits and further corrective action planning if deemed necessary. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to document proposed type of support service on individual treatment plans in two out of six records reviewed.
Client #4 was admitted on January 29, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 12, 2024 with no support services identified.
Client #7 was admitted on December 19, 2023 and discharged on February 22, 2024. A comprehensive treatment plan was developed on January 17, 2024 with no support services identified.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Supervisor will review with staff the policy and procedure to document a proposed type of support service on individual treatment plans, during weekly staff meeting for 1 month. Staff will sign-off that they read and understand the policy and procedure of documenting a proposed type of support service on individual treatment plans. Supervisor will complete weekly chart audits of discharged and open charts to make sure a proposed type of support service is documented on individual treatment plans. Supervisor will also revisit this topic at 30, 60, and 90 days with staff during individual and group supervision providing reminders to document a proposed type of support service on individual treatment plans, and supervisor will complete a corrective action plan with staff who are not adhering to the policy of documenting a proposed type of support services on individual treatment plan, and follow-up this with weekly chart audits to ensure policy is being adhered too, and provide further corrective action planning if needed. |
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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of four applicable records reviewed.
Client #1 was admitted on January 21, 2022 and was still active at the time of the inspection. A treatment plan update was completed on August 18, 2023 and an update was due no later than October 18, 2023; however, it was not completed until October 23, 2024.
Client #2 was admitted on October 19, 2023 and was still active at the time of the inspection. A treatment plan update was completed on December 20, 2023, and an update was due no later than February 20, 2024; however, it was not completed until April 8, 2024.
Client #3 was admitted on July 17, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 18, 2023 and an update was due no later than September 18, 2023; however, it was not completed until September 27, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Supervisor will review the regulatory framework with staff that a treatment plan update needs to be completed every 60 days, during weekly staff meeting for 1 month. Staff will sign-off that they read and understand the policy and regulatory framework of treatment plan updates. Supervisor will complete weekly chart audits of open and discharged charts to verify that treatment plans have been updated within the regulatory time frame. Supervisor will also revisit this topic in 30, 60, and 90 days with staff during individual and group supervision providing reminders that treatment plan updates need to be completed during the regulatory timeframe of 60 days, and provide corrective action plan with staff who are not adhering to regulatory framework of treatment plan updates every 60 days, and again follow-up with weekly chart audits to ensure that the regulatory framework is being adhered too, along with further corrective action planning if deemed necessary. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of outpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 7 days following discharge.
Client #6 was admitted on August 10, 2023 and discharged on October 3, 2023. No follow up was completed.
Client #7 was admitted on December 19, 2023 and discharged on February 22, 2024. No follow up was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor will review the policy and procedure with staff that a follow-up call needs to be completed 7 days following discharge, during weekly staff meeting for 1 month. Staff will sign-off that they read and understand the policy and procedure of making a 7 day outreach call following discharge. Supervisor will complete weekly chart audits of discharged charts to make sure that follow-up calls have been made and documented 7 days following discharge. Supervisor will also revisit this topic at 30, 60, and 90 days during individual and group supervision with staff providing reminders that a 7 day follow-up call needs to be made, and complete a corrective action plan with staff who are not adhering to the policy of making a 7 day follow-up call, and again follow-up with weekly chart audits and further corrective action planning if deemed necessary. |