INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2023 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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709.28 (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 client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in one out of seven records reviewed.
Client #3 was admitted on March 27, 2023 and was discharged on May 1, 2023. A consent form dated March 22, 2023 to a family member and a consent form dated March 23, 2023 to an employer did not list the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 10, 2022 licensing inspection.
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Plan of Correction
Regional Outpatient Clinical Director met with Director of IT and was able to adjust the EMR so that a consent form cannot be saved/finished until all pertinent parts of the form are filled out- this will eliminate the ability to have incomplete consent forms (eg. The purpose not being selected as was discovered in the audit).
In addition to adjusting the consent form in the EMR, the policy regarding obtaining informed consent has been administered to the staff during weekly supervision, which all clinical staff has signed off on having reviewed. Regional Outpatient Clinical Director and Clinical Supervisor held this supervisory meeting and made sure all clinical staff were in attendance. Regional Outpatient Clinical Director and Clinical Supervisor provided any additional training and answered any questions. Clinical Supervisor will be completing weekly chart audits to ensure compliance. This has been implemented effective 6/5/23.
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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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of six applicable records reviewed.
Client #6 was admitted on April 20, 2022 and was still active at the time of the inspection. A treatment plan update was completed on June 13, 2022 and the next update was due no later than August 13, 2022; however, it was completed on August 24, 2022. Additionally, a treatment plan update was completed on January 26, 2023 and the next update was due no later than March 26, 2023; however, it was not completed until April 6, 2023.
Client #7 was admitted on December 21, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 7, 2023 and the next update was due no later than April 8, 2023; however, it was not completed until April 19, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Policy regarding the required timeframe for treatment plan completion has been administered to the staff during weekly supervision, which all clinical staff has signed off on having reviewed. Regional Outpatient Clinical Director and Clinical Supervisor held this supervisory meeting and made sure all clinical staff were in attendance. Regional Outpatient Clinical Director and Clinical Supervisor provided any additional training and answered any questions. Clinical Supervisor will be completing weekly chart audits to ensure compliance. This has been implemented effective 6/5/23. |