INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8 -9, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, The Retreat At White Birch Outpatient, 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill log from December 2018 until September 2019, the facility failed to maintain a written fire drill log that included the exit route used and whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Fire drill log failed to include the exit route and whether the fire alarm was operative. To correct this deficiency, the fire drill log will be updated to include which exit was used and if the fire alarms and smoke detectors were operative during the fire drill.
To prevent re occurrence of this deficiency, the Executive Director and the Intake Coordinator will use this updated fire drill log and be sure all aspects of the fire drill are documented. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure to address Selling or use of illicit drugs on the premises
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has no policy and procedure to address selling or use of elicit drugs an the premise.
To correct this deficiency, a policy and procedure will be developed and entered into the policy and procedure manual. Then we shall use the policy and procedure addressing selling or using illicit drugs on the premises should this action take place.
To prevent re occurrence of this deficiency, the Executive Director will create the necessary policy and procedure. The Executive Director will conduct an in house training with all Outpatient staff to introduce the new policy and procedure addressing selling or using illicit drugs on the premises. The staff will be expected to implement and follow the newly updated policy and procedure should events call for action. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure to address theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Policy and Procedure manual has no policy and procedure to address theft, burglary, break-in or similar incident at the facility. To correct this deficiency, the Executive Director will develop a policy and procedure addressing theft, burglary, break-in or similar incident at the facility.
To prevent re occurrence of this deficiency, the Executive Director will introduce the newly updated policy and procedure to the staff at an in-house training and the expectation that all staff will implement the new policy and procedure addressing this deficiency. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure to address an event at the facility requiring the presence of police, fire or ambulance personnel
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our policy and procedure manual failed to develop and implement a policy and procedure to address an event at the facility requiring the presence of police, fire or ambulance personnel. To correct this deficiency, the Executive Director develop a policy and procedure addressing this deficiency.
To prevent re occurrence of this deficiency, an in-house training with all staff will be conducted by the Executive Director introducing the new policy and procedure and the implementation of the new policy and procedure by all staff. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of Seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in five client records reviewed.
Client #1 was admitted on February 4, 2019 and was still active at the time of the inspection. A treatment plan update was completed on Feburary 4, 2019 and the next update was due no later than April 4, 2019; however, there was no update documented in the record at the time of the inspection.
Client #2 was admitted on April 18th, 2019 and was still active at the time of the inspection. A treatment plan update was completed on July 29, 2019 and the next update was due no later than September 29, 2019 ; however, there was no update documented in the record at the time of the inspection.
Client #4 was admitted on July 2, 2019 and was still active at the time of the inspection. A treatment plan update was completed on July 4, 2019 and the next update was due no later than September 4, 2019; however, there was no update documented in the record at the time of the inspection.
Client #5 was admitted on November 13, 2018 and was discharged on June 4, 2019. A treatment plan update was completed on November 13, 2018, and the next update was due no later than January 13, 2019; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on December 4, 2018 and was discharged on April 10, 2019. A treatment plan update was completed on December 27, 2019 and the next update was due no later than February 27, 2019; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document treatment plan updates within the regulatory time frame in 5 client records reviewed. To correct this deficiency, a checklist of all aspects of the client files including treatment plan updates with a clear picture of regulatory time frames will be taped to the inside front cover of the client file as a template for the counselors to keep the files within the regulations.
To prevent re occurrence of this deficiency, the Executive Director and Intake Coordinator will conduct bi weekly staff meeting addressing client files including treatment plan updates done in a regulatory fashion. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summaries and aftercare plans.
Client #5 was admitted on November 13, 2018 and was discharged on June 4, 2019. The client record did not contain documentation of a discharge summary and an aftercare plan.
Client #7 was admitted on December 4th, 2019 and was discharged on April 10th, 2019. The client record did not contain documentation of an aftercare plan.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The facility failed to provide a complete client record including discharge summaries and aftercare plans. To correct this deficiency, a checklist of all required aspects of the client file including discharge summaries and aftercare plans will be taped to the inside front cover of all client files at admission.
To prevent re occurrence of this deficiency, the Executive Director and the Intake/Admission Coordinator will conduct bi-weekly staff meeting addressing and reviewing all client files to ensure that all required documentation is completed to keep the facility within the regulations. |