INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 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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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in five out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed between within seven days following admission.
Client #2 was admitted on September April 7, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 14, 2023; however, it was not completed until April 19, 2023.
Client #3 was admitted on April 21, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 28, 2023; however, it was not completed until May 4, 2023.
Client #4 was admitted on April 17, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 24, 2023; however, it was not completed until May 4, 2023.
Client #6 was admitted on August 23, 2022 and was discharged on January 5, 2023. A comprehensive treatment plan was due no later than August 30, 2022; however, it was not completed until November 4, 2022.
Client #7 was admitted on October 18, 2022 and discharged on February 7, 2023. A comprehensive treatment plan was due no later than October 25, 2022; however, it was not completed until November 25, 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. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three discharged records reviewed.
Client #6 was admitted on August 23, 2022 and was discharged on January 5, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy regarding the need for required discharge summary 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. |