INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Retreat at White Birch 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on May 23, 2022 and was due to have the communicable disease trainings no later than May 23, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee # 3 failed to have health-related trainings done in the time required by regulation.
Employee # 3 was informed when hired to have the health-related trainings including TB/STD training completed within the 1st year of employment but failed to get the training completed.
To correct this deficiency, Employee #3 completed the training on 09/19/2023
To prevent this deficiency from reoccurring, the clinical director will monitor the training requirements of the clinical staff and encourage the staff to have the required trainings completed in the time allowed by the regulations |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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 a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling room.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure privacy by having a camera operating in a group counseling room.
To correct this deficiency, the camera was disconnected and removed from the group room to ensure privacy during group counseling
To prevent the re-occurrence of this deficiency, the Executive Director will inspect all rooms on a monthly basis to be sure cameras are never installed in any room where group counseling occurs |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor. There were boxes of food on the floor in the storage area.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The facility failed to store food properly. There were boxes of potato chips that were stacked on top of each other on the floor.
To correct this deficiency, the Executive Director had one of the girls remove the contents from the boxes and store them properly in the cabinets.
To prevent the re-occurrence of this deficiency, the Clinical Director and the Executive Director will inspect daily to make sure that all food products are stored properly and no boxes of food are left on the floor at anytime |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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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 specific information to be disclosed in two out of eight records reviewed.
Client #1 was admitted on April 20, 2023 and was still active at the time of the inspection. Four release of information forms signed and dated on August 1, 2023 to medical providers did not include the specific information to be disclosed.
Client #7 was admitted on March 31, 2023 and was discharged on April 12, 2023. A release of information form signed and dated April 11, 2023 did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed
To correct this deficiency, the consents for these clients were remade and resigned by the client and their counselor to specify the information that was being released to coordinate the proper care.
To prevent the reoccurrence of this deficiency, the informed and voluntary consents and have been reworded and redesigned to eliminate broad terms and use more individualized options for sharing client information with outside resources.
The clinical director and intake coordinator will monitor the informed voluntary consents to ensure that they are client-specific and being filled out the correct way. |