INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 10, 2024 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to document proposed type of support service on individual treatment plans in three out of seven records reviewed.
Client #2 was admitted on April 5, 2024 and was still active at the time of the inspection. A comprehensive treatment plan dated April 5, 2024 did not list support services.
Client #4 was admitted on March 19, 2024 and was still active at the time of the inspection. A comprehensive treatment plan dated March 19, 2024 did not list support services.
Client #5 was admitted on December 19, 2023 and was discharged on January 5, 2024. A comprehensive treatment plan dated December 21, 2023 did not list support services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Policy regarding treatment planning and associated documentation has been administered to the staff during weekly supervision with the Clinical Supervisor, with emphasis on community support. Clinical Supervisor answered additional questions and ensured understanding of the material. All clinical staff have signed off on the policy indicating that it has been reviewed. Clinical Supervisor will be completing weekly chart audits to ensure compliance. This has been implemented effective 5/3/24. |
709.83(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed seven days following discharge.
Client #5 was admitted on December 19, 2023 and discharged on January 5, 2024. A follow up was due no later than January 12, 2024; however, none was completed.
Client #6 was admitted on January 2, 2024 and was discharged on January 17, 2024. A follow up was due no later than January 24, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Policy regarding the required timeframe for follow-up call completion has been administered to the staff during weekly supervision with the Clinical Supervisor. Clinical Supervisor answered additional questions and ensured understanding of the material. All clinical staff have signed off on the policy indicating that it has been reviewed. Chart checks are routinely completed post-discharge but are often conducted prior to day 7 and thus would not encompass follow-up contact. Clinical Supervisor will conduct weekly chart audits which focus on post-discharge outreach. This has been implemented effective 5/3/24. |
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.
|
Observations
Based on a review outpatient of client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven records reviewed.
Client #8 was admitted on February 26, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was completed on March 1, 2024.
Client #9 was admitted on March 3, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was completed on March 5, 2024.
Client #10 was admitted on August 26, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was completed on August 26, 2023.
Client #11 was admitted on February 6, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was completed on February 6, 2024.
Client #12 was admitted on October 25, 2023 and was discharged on December 30, 2023. The comprehensive treatment plan was completed on October 28, 2023.
Client #13 was admitted on September 18, 2023 and was discharged on February 3, 2024. The comprehensive treatment plan was completed on September 25, 2023.
Client #14 was admitted on August 9, 2023 and was discharged on February 29, 2024. The comprehensive treatment plan was completed on September 11, 2023.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Policy regarding treatment planning and associated documentation has been administered to the staff during weekly supervision with the Clinical Supervisor, with emphasis on community support. Clinical Supervisor answered additional questions and ensured understanding of the material. All clinical staff have signed off on the policy indicating that it has been reviewed. Clinical Supervisor will be completing weekly chart audits to ensure compliance. This has been implemented effective 5/3/24. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 7 days following discharge.
Client #12 was admitted on October 25, 2023 and discharged on December 30, 2023. A follow up was due no later than January 6, 2024; however, none was completed.
Client #13 was admitted on September 18, 2023 and was discharged on January 3, 2024. A follow up was due no later than January 10, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Policy regarding the required timeframe for follow-up call completion has been administered to the staff during weekly supervision with the Clinical Supervisor. Clinical Supervisor answered additional questions and ensured understanding of the material. All clinical staff have signed off on the policy indicating that it has been reviewed. Chart checks are routinely completed post-discharge but are often conducted prior to day 7 and thus would not encompass follow-up contact. Clinical Supervisor will conduct weekly chart audits which focus on post-discharge outreach. This has been implemented effective 5/3/24. |