INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The Project/Facility Director confirmed that no annual financial audit was conducted for the preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Annual Audit is currently being conducted and is being monitored by the Chief Financial Officer and will be complete by the end of the month.
The CFO will ensure compliance via annual reviews. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to include documentation verifying written acknowledgement by clients that they had been informed of their rights to appeal a decision limiting access to their records to the director, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records and the right to submit rebuttal data or memoranda to their own records, in 14 of 14 client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient Bill of Rights has been updated so patients have been informed of their rights to appeal a decision limiting access to their records to the director, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records and the right to submit rebuttal data or memoranda to their own records, in 14 of 14 client records reviewed. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to provide documentation that Client #7 was notified, in writing, of the facility's decision to involuntarily terminate the client from treatment. Client #7 was admitted to the partial hospitalization level of care on June 6, 2018 and was administratively discharged on July 13, 2018.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All clinical staff have been informed to ensure that termination letters are sent. However, in this particular patient's case, the patient was homeless and a call was made to the patient. |