INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 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:
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Plan of Correction
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709.92(a) 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:
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Observations
Based on a review of outpatient client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within seven days following admission.
Client #4 was admitted on December 1, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 8, 2023; however, it was not completed until January 24, 2024.
Client #5 was admitted on August 31, 2023 and was discharged on January 4, 2024. A comprehensive treatment plan was due no later than September 7, 2023; however, it was not completed until September 8, 2023.
Client #6 was admitted on September 13, 2023 and discharged on January 26, 2024. A comprehensive treatment plan was due no later than September 20, 2023; however, it was not completed until September 27, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Supervisor will review the policy and procedure that a treatment plan needs to be developed within 7 days of admission, during weekly staff meeting for 1 month. Staff will sign-off that they understand this treatment plan policy and procedure, and supervisor will complete weekly chart audits of open and discharged charts to verify that individual treatment plans are developed with the client within 7 days of admission. Supervisor will also revisit this policy and procedure during individual and group supervision at 30, 60, and 90 days with staff and complete a corrective action plan with staff who are not adhering to the policy and procedure of developing an individual treatment plan with the client within 7 days of admission, and follow-up this with further weekly chart audits and corrective action planning if deemed necessary. |
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 a review of outpatient client records, the facility failed to document proposed type of support service on individual treatment plans in three out of seven records reviewed.
Client #1 was admitted on August 11, 2023 and was still active at the time of the inspection. A treatment plan was completed on August 14, 2023.
Client #5 was admitted on August 31, 2023 and was discharged on January 4, 2024. A treatment plan was completed on September 8, 2023.
Client #6 was admitted on September 13, 2023 and was discharged on January 26, 2024. A treatment plan was completed on September 27, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Supervisor will review with staff the regulatory framework to documenting a proposed type of support service on individual treatment plans, during weekly staff meeting for 1 month. Staff will sign-off that they understand the regulatory framework of documenting a proposed type of support service on individual treatment plans. Supervisor will complete weekly chart audits of discharged and open charts to make sure a proposed type of support service is documented on individual treatment plans. Supervisor will also revisit this topic at 30, 60, and 90 days with staff during individual and group supervision providing reminders to document a proposed type of support service on individual treatment plans, and supervisor will complete a corrective action plan with staff who are not adhering to the policy of documenting a proposed type of support services on individual treatment plan, and follow-up this with weekly chart audits to ensure this regulatory framework is followed, and provide further corrective action planning if deemed necessary. |