INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2014 by staff from the 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.
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Plan of Correction
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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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 document type and frequency and support services on an individual treatment and rehabilitation plan in three of three records reviewed.
The findings include:
Three client records requiring documentation of type and frequency and support services on an individual treatment plan were reviewed on March 6, 2014. The facility failed to document type and frequency and support services on an individual treatment plan in client records # 3, 4, and 5.
The findings were reviewed confirmed by the Facility Director.
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Plan of Correction
All clinical staff will be trained to complete treatment plans to include type of support services in all patient records. This will be monitored via chart checks done by clinical supervisor under the direction of Executive Director |