INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 2021 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of eleven fire drills on July 1, 2021, the facility failed to set off a fire alarm or smoke detector during each fire drill reviewed. The facility used a verbal staff announcement to conduct monthly fire drills on the following dates: February 15, 2021, April 6, 2021, May 28, 2021, June 1, 2021 and June 2, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will conduct full fire drills as required, utilizing the fire alarm or smoke detector for each fire drill going forward. Staff will no longer conduct fire drills by verbal staff announcement.
This will be monitored by the project director. Project director will complete fire drills as required, or assign a designee to complete fire drills. All staff has been informed and trained on how to properly complete fire drills n using the fire alarm or smoke detector. Project director will be monitoring each month to ensure all fire drills are completed as required. |
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.
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Observations
Based on a review of client records, the project failed to document individual counseling twice weekly in three out of seven applicable records reviewed. Client #1 was admitted on May 24, 2021 and was still active at the time of the inspection. There were no individual counseling sessions documented for the week of June 21-June 25, 2021. Client #2 was admitted on May 14, 2021 and was still active at the time of the inspection. There was only one individual counseling session documented for the week of June 14-June 18, 2021. The documented session was on June 15, 2021. Client #3 was admitted on April 29, 2021 and was still active at the time of the inspection. There were no individual counseling sessions documented for the week of June 14-June 18, 2021. These findings were reviewed with the project during the licensing process.
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Plan of Correction
Clinical Supervisor shall review regulation above. Staff shall provide individual counseling sessions at least 2x weekly. Clinical Supervisor will complete routine chart reviews weekly to ensure compliance. |