INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1, 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 seven 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 from November 2020 through May 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.
Facility director or assigned designee will be completing each fire drill. Each person responsible for fire drills has been retrained to ensure they know that a smoke detector or fire alarm needs to be used. Facility director will be checking monthly to ensure that each fire drill is completed correctly based off the requirements. |
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 seven client records on June 30, 2021, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two records reviewed. Client #2 was admitted on March 1, 2021 and was active at the time of the inspection. A consent to release information to a health insurance provider dated March 18, 2021 included bio-psych social assessment. Client #6 was admitted on November 23, 2020 and was discharged on March 4, 2021. A consent to release information to a health insurance provider dated April 1, 2021, included diagnosis and related information, history and physical, bio-psych social assessment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff has been retrained on the 4 PA. Code 255.5 (b) by facility director. Moving forward, all clinical staff will be checking releases of information for any patient coming from the inpatient facility to ensure they have the correct limits established by 4 Pa. Code 255.5 (b). New releases of information will be made as needed. Additionally any external referrals will have new releases created that shall abide by 4. PA code 255.5 where applicable. The facility director will be doing chart checks at least two times a week to ensure ongoing compliance with keeping client identifying information within the limits established by 4 Pa. Code 255.5 (b) on all releases of information.
Any consent forms found during chart checks that are not completed correctly will be fixed by the facility director or designee and resigned by the patient immediately, this included client #2's chart. |