INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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:
|
Plan of Correction
|
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.
|
Observations
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 one of seven client records reviewed.
Client # 5 was admitted to the outpatient activity on April 13, 2020 and was discharged on August 12, 2020. There was a consent to release information form to the funding source, signed and dated by the client on February 12, 2020, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5 which included the history and physical.
This finding was reviewed with facility staff during the licensing inspection.
|
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. 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. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
The facility failed to document the dated signature of the client on informed and voluntary consent to release information forms in two of seven client records reviewed.
Client #2 was admitted to the outpatient activity on June 10, 2020 and was still active at the time of the inspection. The release of information forms to the funding source and an emergency contact were both signed and dated by the witness on June 10, 2020.
Client #4 was admitted to the outpatient activity on March 23, 2020 and was discharged on July 23, 2020. The release of information forms to the funding source and an emergency contact were both signed and dated by the witness on March 23, 2020.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Moving forward to ensure that patients can sign consents from a remote site when conducting telehealth appointments, we will be working with electronic signatures within the EMR, or consents will be emailed to patient to be signed and emailed back to clinical staff. If consents are emailed, once the clinical staff receives the consents they will be scanned into the patient chart. If there is a lack of access to technology, the patient will be mailed their consents via USPS to be signed by the patient, then returned to facility via USPS. These will then be scanned into the patient charts. Chart checks will be completed at least two times a week by the facility director to ensure ongoing compliance.
Deficiency will be corrected in the active patient's chart on November 27th, 2020. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
The facility failed to document the type and frequency of treatment and rehabilitation services the client is to receive on the client's individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #2 was admitted on June 10, 2020 and was still active at the time of inspection. The individual treatment and rehabilitation plan was completed on June 15, 2020.
Client #3 was admitted on March 12, 2020 and was still active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 23, 2020.
Client #4 was admitted on March 23, 2020 and was discharged on July 23, 2020. The individual treatment and rehabilitation plan was completed on April 1, 2020.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The facility director has reviewed the existing policy on treatment plans with all clinical staff. Clinical staff will be completing treatment plans with all patients, and they will have documented the type and frequency of treatment and rehabilitation services the patient is to receive. Chart checks will be completed at least two times a week by facility director to ensure ongoing compliance.
Deficiency will be corrected in all active patient's charts on November 24th. |