INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on December 7, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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709.28 (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.
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Observations
Based on a review of fourteen client records, the facility failed to keep consent to release forms to funding source within limits set forth by 255.5 in all fourteen records.
This is a repeat citation from the August 2, 2019 inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
This POC was already in effect 1 month prior to inspection. Staff was educated on and trained on PA Code 255.5. Staff was trained how to properly fill out consents so as not to exceed 255.5
Chart reviews will be done weekly by Director/supervisor in order to ensure ongoing compliance.
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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 a review of fourteen client records, the facility failed to ensure that all consent to release forms included the purpose of disclosure.
Client #3 was admitted on March 16, 2020 and was still active at the time of the inspection. Consent to release forms for the funding source, PCP and emergency contact signed and dated February 11, 2020 all failed to include purpose to disclosure.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
This POC was already in effect 1 month prior to inspection. Staff was trained how to properly fill out release forms and was reminded to ensure all sections of release forms are completed.
Chart reviews will be done weekly by Director/supervisor in order to ensure ongoing compliance with this matter. |