INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2023 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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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in one out of seven records reviewed.
Client #2 was admitted on February 8, 2023 and was still active at the time of the inspection. A consent form dated February 8, 2023 to an insurance company did not list the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Regional Outpatient Clinical Director met with Director of IT and was able to adjust the EMR so that a consent form cannot be saved/finished until all pertinent parts of the form are filled out- this will eliminate the ability to have incomplete consent forms (eg. The purpose not being selected as was discovered in the audit).
In addition to adjusting the consent form in the EMR, the policy regarding obtaining informed consent has been administered to the staff during weekly supervision, which all clinical staff has signed off on having reviewed. Regional Outpatient Clinical Director and Clinical Supervisor held this supervisory meeting and made sure all clinical staff were in attendance. Regional Outpatient Clinical Director and Clinical Supervisor provided any additional training and answered any questions. Clinical Supervisor will be completing weekly chart audits to ensure compliance. This has been implemented effective 6/5/23.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual of every ninety days, in two out of six applicable records reviewed.
Client #3 was admitted on November 18, 2022 and was still active at the time of the inspection. There have been no case consultations completed.
Client #4 was admitted on admitted on January 11, 2023 and was still active at the time of the inspection. A case consultation was due on April 11, 2023; however, it was not completed until May 5, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Regional Director is reviewing the policy for Case Consultation and will be changing the policy to reflect "at least one case consult per level of care, and at time of discharge" to mitigate the risk of being non-compliant with the current reading of the policy (once every 90 days).
The policy change will be proposed and approved by the Policy and Procedure Committee. Policy will officially be rolled out and effective 6/19/23. Once officially rolled out, Regional Outpatient Clinical Director will set up a supervision meeting for all OP sites. Regional Outpatient Clinical Director will review new policy with all clinical staff. Clinical staff will sign off that they understand the policy to guarantee that all staff are fully informed of how to properly do Case Consultations.
Clinical Supervisor will be completing weekly chart audits to ensure ongoing compliance. |