INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 15-17, 2013 by staff from the Division of Drug and Alcohol 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.
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Plan of Correction
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during the physical plant tour, the facility failed to ensure privacy so counseling could not be seen or heard outside the counseling room.
The findings include:
The physical plant tour took place on April 17, 2013 around 9 am. The facility is a one story building that has counseling offices and one large group room. The large group room is located in the front of the building. The group room failed to have a door and included a rectangular wall opening that faced the entryway and reception area and allowed for staff and visitors to be able to see and hear group sessions. The group room also included three exterior windows that failed to have window coverings permitting the potential for counseling sessions to be observed from the exterior of the building.
The front and back doors of the building also failed to have covering to prevent view from outside the facility. A counselor's office had two windows that did not have window coverings.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in two of four residential treatment and rehabilitation records.
The findings include:
Ten client records were reviewed on April 16-17, 2013. Four of the ten client records were reviewed from the partial hospitalization activity. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records # 9 and 10 and did not include a composite picture of the client.
The psychosocial evaluations in client records # 9 and 10 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 9 and 10 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records # 9 and 10 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 9 and 10 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client record #10 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with the project director/facility director on April 17, 2013, confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the client's individual treatment and rehabilitation plan in four of four client records.
The findings included:
Ten client records were reviewed on April 16-17, 2013. Four of the ten client records were reviewed from the partial hospitalization activity, #7, 8, 9 and 10. The type and frequency of services was required in the individual treatment and rehabilitation plan in four client records. Four of the four client records did not contain documentation of type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document the support services on the individual treatment and rehabilitation plan in three of four client records.
The findings included:
Ten client records were reviewed on April 16-17, 2013. Four of the ten client records were reviewed from the partial hospitalization activity, # 7, 8, 9 and 10. The support services were required in the individual treatment and rehabilitation plan in four client records. Three of the four client records, #s 7, 8 and 10, did not include documentation of support services on the individual treatment and rehabilitation plan.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in two of four records reviewed in the partial hospitalization activity.
The findings include:
Ten client records were reviewed on August 16-17, 2013. Four of the ten client records were from the partial hospitalization activity. Four of those four records were required to document individual counseling at least twice weekly, #7, 8, 9 and 10. Two of those four did not document individual counseling at least twice weekly, # 9 and 10.
Client # 9 was admitted on March 21, 2013 and discharged on April 12, 2013. There was only one documentation of a individual session, March 26, 2013.
Client # 10 was admitted on February 26, 2013 and discharged on April 5, 2013. There were only two individual sessions documented, March 8, 2013 and February 28, 2013.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to include all the components in the aftercare plan in two of two discharge client records.
The findings include:
Ten client records were reviewed on April 16-17, 2013. Four of the ten client records were reviewed from the partial hospitalization activity. Two of the four were discharge clients, #9 and 10. Aftercare plans are to include the clients goals with time frames, support services, contact person and reentry process.
Client #9 was admitted on March 21, 2013 and discharged on April 12, 2013. The aftercare plan was documented on April 12, 2013. The aftercare plan was missing the goals with time frames, support services, the contact person and reentry process.
Client #10 was admitted on February 26, 2013 and discharged on April 5, 2013. The aftercare plan was documented on April 5, 2013. The aftercare plan was missing the goals with time frames, support services, the contact person and reentry process.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.83(a)(8) LICENSURE Client records
709.83. 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:
(8) Record of services provided.
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Observations
Based on a review of client records, the facility failed to provide a record of service in four of four records reviewed.
The findings include:
Ten client records were reviewed on April 16-17, 2013. Four of the ten client records were reviewed from the partial hospitalization activity, # 7, 8, 9 and 10. The facility failed to have available record of service documentation in all records reviewed, #7, 8, 9 and 10.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to include the required components in the discharge summary in two of four discharge records.
The findings include:
Ten client records were reviewed on April 16-17, 2013. Four of the ten client records were reviewed from the partial hospitalization activity, #7, 8, 9 and 10. Two of the four were discharge clients, #9 and 10. The facility failed to include the reason for treatment in the discharge summary documentation for client's #9 and 10.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in four of six residential treatment and rehabilitation records.
The findings include:
Ten client records were reviewed on April 16-17, 2013. Six of the ten client records were reviewed from the outpatient activity. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records # 2, 4, 5 and 6 did not include a composite picture of the client.
The psychosocial evaluations in client records # 2, 4, 5 and 6 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 2, 4, 5 and 6 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records # 2, 4, 5 and 6 did not include an evaluation of the client's coping mechanisms and how they would relate to/or impact treatment.
The psychosocial evaluations in client records # 2, 4, 5 and 6 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records # 2, 4, 5 and 6 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of six client records.
The findings included:
Ten client records were reviewed on April 16-17, 2013. Six of the ten client records were reviewed from the outpatient activity, #1, 2, 3, 4, 5 and 6. The type and frequency of services was required in the individual treatment and rehabilitation plan in five client records. Five of the six client records did not document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan #2, 3, 4, 5 and 6.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document the support services on the individual treatment and rehabilitation plan in four of six client records.
The findings included:
Ten client records were reviewed on April 16-17, 2013. Six of the ten client records were reviewed from the outpatient activity, #1, 2, 3, 4, 5 and 6. The support services were required in the individual treatment and rehabilitation plan in six client records. Four of the six client records did not contain documentation of support services on the individual treatment and rehabilitation plan, #2, 3, 4 and 6.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to provide a record of service in six of six records reviewed.
The findings include:
Ten client records were reviewed on April 16-17, 2013. Six of the ten client records were reviewed from the outpatient activity, #1, 2, 3, 4, 5 and 6. The facility failed to have available record of service documentation in all records reviewed, #1, 2, 3, 4, 5 and 6.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to include all the components in the aftercare plan three of three discharge client records.
The findings include:
Ten client records were reviewed on April 16-17, 2013. Six of the ten client records were reviewed from the outpatient activity, #1, 2, 3, 4, 5 and 6. Three of the six were discharge clients, #4, 5 and 6. Aftercare plans are to include the clients goals with time frames, support services, contact person and reentry process.
Client #4 was admitted on February 22, 2013 and discharged on April 1, 2013. The aftercare plan was documented on April 1, 2013. The aftercare plan was missing the goals with time frames and reentry process.
Client #5 was admitted on February 11, 2013 and discharged on April 5, 2013. The aftercare plan was documented on April 5, 2013. The aftercare plan was missing the goals with time frames and reentry process.
Client #6 was admitted on June 12, 2012 and discharged on March 27, 2013. The aftercare plan was documented on March 27, 2013. The aftercare plan was missing the goals with time frames and reentry process.
An interview with the project director/facility director on April 17, 2013 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to include components in the discharge summary.
The findings include:
Ten client records were reviewed on April 16-17, 2013. Six of the ten client records were reviewed from the outpatient activity, #1, 2, 3, 4, 5 and 6. Three of the six were discharge clients, #4, 5 and 6. The following components are required to be documented on the discharge summary; reason for treatment, services offered, respond to treatment and client status. The facility failed to include reason for treatment, services offered and the client's response to treatment on the discharge summary for client's #4, 5 and 6.
An interview with the project director/facility director on April 17, 2013, confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |