INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lakeside NEPA, Inc. 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 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in five out of seven client records reviewed.
Client #2 was admitted on August 1, 2023 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated August 1, 2023 and releases of information form for a legal and social service provider dated on October 23, 2023 were offered to the client.
Client #3 was admitted on July 31, 2023 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated July 31, 2023 was offered to the client.
Client #5 was admitted on August 24, 2023 and was discharged on October 19, 2023. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated August 24, 2023 was offered to the client.
Client #6 was admitted on May 12, 2023 and was discharged on September 8, 2023. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated May 12, 2023 was offered to the client.
Client #7 was admitted on January 13, 2023 and was discharged on November 8, 2023. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated January 13, 2023 was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.28(d) related to confidentiality of a client consent to be offered to the client and a copy maintained in the client record. Based on these findings the Executive Director submitted to the electronic medical record system to include the information to reflect the ability to accept or decline a copy of the consent. The electronic medical record system updated the consent on 12/7/2023. The Executive Director retrained the clinical team on 12/8/2023 to offer the client a copy of all releases and ensure the client accepts or declines all consent forms. The Executive Director and Chief Operating Officer will conduct monthly chart audits to ensure all consent forms are completed correctly. |
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 five applicable records reviewed.
Client #3 was admitted on July 31, 2023 and was still active at the time of the inspection. A treatment plan was completed on August 18, 2023 and the next update was due no later than October 18, 2023; however, it was not completed until October 23, 2023.
Client #6 was admitted on May 12, 2023 and was discharged on September 8, 2023. A treatment plan was completed on June 1, 2023 and the next update was due no later than August 1, 2023; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.92(b) Treatment and Rehabilitation plan to be reviewed and updated at least every 60 days. Based on these findings the Executive Director retrained the clinical staff on 12/05/2023 during the treatment team meeting on the importance of completing treatment plans at the specific due date. The Executive Director and the Chief Operating Officer will conduct monthly chart audits to ensure the clinical team completes treatment plans on time. |