INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 2, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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:
|
Plan of Correction
|
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
|
Observations
Based on a physical plant inspection on August 2, 2019, it was observed that the facility failed to maintain trash containers preventing the penetration of insects and rodents. The trash dumpster was observed open during the physical plant inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A daily walk-thru by the Admin Asst staff will ensure the garbage container lid is closed. If it is open, the person will close it. The Chief Clinical Officer will check it monthly to ensure this procedure is being followed. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of the facility's policy and procedure manual on July 30, 2019, the project director failed to annually update and sign the written manual. The manual was last signed on January 1, 2018.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Chief Clinical Officer will ensure the policies are signed annually. The PI Assistant will set a reminder annually on the calendar to ensure this occurs. |
709.28 (c) 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.
|
Observations
Based on the review of fourteen client records on August 2, 2019, the facility failed to document an informed and voluntary consent to release information prior to the disclosure of information in client record #9.
Client #9 was admitted on June 1, 2019 and was still active at the time of the inspection. A case consultation note for July 3, 2019 stated a fax was sent to an insurance company; however, there was no proper consent to release information form signed by the client prior to the disclosure.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will provide a training by Sept 1, 2019 to inform all clinical and support staff that releases for outside must be signed prior to any phone calls made. Weekly chart reviews by the Clinical Supervisor will be conducted to ensure this procedure is being followed. The Chief Clinical Officer will conduct monthly reviews to ensure this is in compliance. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on the review of fourteen client records on August 2, 2019, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client record #'s 1, 2, 3, 4, 5, 6, and 11.
Client #1 was admitted on June 21, 2019 and was still active at the time of the inspection. A consent to release form was signed and dated on June 21, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #2 was admitted on June 10, 2019 and was still active at the time of the inspection. A consent to release form was signed and dated on June 10, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #3 was admitted on June 3, 2019 and was still active at the time of the inspection. A consent to release form was signed and dated on June 3, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #4 was admitted on February 28, 2019 and was discharged on March 25, 2019. A consent to release form was signed and dated on February 28, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #5 was admitted on June 27, 2019 and was discharged on July 29, 2019. A consent to release form was signed and dated on June 27, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #6 was admitted on January 28, 2019 and was discharged on March 7, 2019. A consent to release form was signed and dated on January 28, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #11 was admitted on April 13, 2019 and was discharged on May 23, 2019. A consent to release form was signed and dated on April 13, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Consent Forms will be modified to ensure the items being released do not exceed the 4 PA Code 255.5. The Clinical Supervisor will conduct a training to ensure all staff are informed of this matter. The Chief Clinical Officer will conduct weekly reviews of clinical records to ensure compliance with this regulation.
Chief Clinical Officer will conduct a review of all current client's records to ensure all consents to release information are within the limits of 4 Pa. Code 255.5 when applicable have the client sign a new consent to release information form. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of seven partial hospitalization client records on August 2, 2019, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plans in six charts reviewed.
Client #2 was admitted on June 10, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated June 17, 2019, indicated group sessions five days a week and individual sessions twice a week. For the week of June 23 - 29, 2019, the client received three groups sessions on June 25, 27 and 28, 2019 and one individual session on June 25, 2019.
Client #3 was admitted on June 3, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated July 18, 2019, indicated group sessions five days a week. For the week of July 21 - 27, 2019, the client received three group sessions (July 24, 25 and 26, 2019) and one excused absence from group session on July 23, 2019.
Client #4 was admitted on February 28, 2019 and discharged on March 25, 2019. The comprehensive treatment plan, dated March 5, 2019, indicated two individual sessions per week. For the week of March 17-23, 2019, the client did not receive any individual sessions.
Client #5 was admitted on June 27, 2019 and discharged on July 29, 2019. The comprehensive treatment plan, dated June 27, 2019, indicated two individual sessions per week and five group sessions per week. For the week of July 21 - 27, 2019, the client received four group sessions (July 22, 23, 24, and 25, 2019) and one individual session on July 24, 2019.
Client #6 was admitted on January 28, 2019 and discharged on March 7, 2019. The comprehensive treatment plan, dated February 2, 2019, indicated two individual sessions per week and five group sessions per week. For the week of February 10 - 16, 2019, the client received four group sessions (February 11, 12, 13, and 14, 2019) and no individual sessions.
Client #7 was admitted on December 27, 2018 and discharged on February 23, 2019. The comprehensive treatment plan, dated January 7, 2019, indicated two individual sessions per week and five group sessions per week. For the week of January 7 - 12, 2019, the client received four group sessions (January 7, 8, 10, and 11, 2019) and one individual session on January 10, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By September 2, all clinical staff will be trained on this regulation, that all patients must have the required individual sessions as stated by the Clinical Supervisor. The Clinical Supervisor will conduct weekly chart reviews to ensure compliance. The Chief Clinical Officer will review charts on a monthly basis to ensure compliance. |
709.82(d)(1) 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:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of seven partial hospitalization client records on August 2, 2019, the facility failed to provide individual counseling sessions at least twice a week to client #'s 2, 3, 4, 5, 6 and 7.
Client #2 was admitted on June 10, 2019 and was still active at the time of the inspection. For the week of June 23 - 29, 2019, the client received one individual session on June 25, 2019.
Client #3 was admitted on June 3, 2019 and was still active at the time of the inspection. For the week of July 14 - 20, 2019, client received zero individual sessions. For the week of July 21 - 27, 2019, the client received one individual session on July 24, 2019.
Client #4 was admitted on February 28, 2019 and discharged on March 25, 2019. For the week of March 17 - 23, 2019, the client received zero individual sessions.
Client #5 was admitted on June 27, 2019 and discharged on July 29, 2019. For the week of July 21 - 27, 2019, the client received one individual session on July 24, 2019.
Client #6 was admitted on January 28, 2019 and discharged on March 7, 2019. For the week of February 10 - 16, 2019, the client received zero individual sessions.
Client #7 was admitted on December 27, 2018 and discharged on February 23, 2019. For the week of January 6 - 12, 2019, the client received one individual session on January 10, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By September 2, all clinical staff will be trained on this regulation, that all patients must have the required individual sessions as stated by the Clinical Supervisor. The Clinical Supervisor will conduct weekly chart reviews to ensure compliance. The Chief Clinical Officer will review charts on a monthly basis to ensure compliance. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
|
Observations
Based on a review of seven partial hospitalization client records on August 2, 2019, the facility failed to provide a complete client record, which is to include a case consultation in client record #'s 4, 5, 6 and 7.
Client #4 was admitted on February 28, 2019 and discharged on March 25, 2019.
Client #5 was admitted on June 27, 2019 and discharged on July 29, 2019.
Client #6 was admitted on January 28, 2019 and discharged on March 7, 2019.
Client #7 was admitted on December 27, 2018 and discharged on February 23, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By Sept 2, 2019, the clinical supervisor will conduct a training with clinical staff to inform all patients must have a case consultation based on level of care and by the stated regulation. Clinical Supervisor will conduct weekly chart reviews to ensure compliance. The Chief Clinical Officer will conduct monthly chart reviews to ensure compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of seven outpatient client records on August 2, 2019, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plans in three charts reviewed.
Client #8 was admitted on June 21, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated June 24, 2019, indicated group sessions three times per week. For the week of July 14 - 20, 2019, the client received one group session on July 17, 2019. For the week of July 21- 17, 2019, the client received one group session on July 24, 2019.
Client #11 was admitted on April 13, 2019 and was discharged on May 23, 2019. The comprehensive treatment plan, dated April 22, 2019, indicated three group sessions per week. For the week of April 28 - May 4, 2019, the client received one group session on May 1, 2019.
Client #12 was admitted on June 17, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated June 20, 2019, indicated group sessions five days per week and individual sessions two days per week. For the week of July 7 - 13, 2019, the client received three group sessions on July 8, 10, and 12, 2019 and zero individual sessions.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By September 2, all clinical staff will be trained on this regulation, that all patients must have the required individual sessions as stated by the Clinical Supervisor. The Clinical Supervisor will conduct weekly chart reviews to ensure compliance. The Chief Clinical Officer will review charts on a monthly basis to ensure compliance. |