INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3, 2022, 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 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of the Staffing Requirements Facility Summary Reports, the Project failed to have a full-time clinical supervisor for every eight Full Time Equivalent (FTE) counselors or counselor assistants.
The Project FTE is determined by adding the total number of hours each facility in the Project devotes to their clients by the facility's work week. Then, if the FTE is between 8 and 15, the Project is required to have at least one full-time clinical supervisor.
The Project ' s FTE is as follows:
Total hours devoted to clients across the Project is 398. The Project ' s work week is 40 hours. The Project reported no full-time clinical supervisors. The Project ' s FTE calculation is as follows: 398/40 = 9.9(FTE); 9.9 counselor FTE hours requires 1 full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility failed to ensure that a full-time clinical supervisor was hired as the FTE calculation of 8 counselors was met for the project.
To correct this deficiency, a full-time clinical supervisor that meets the educational and experiential requirements has been promoted to the position.
To prevent the re-occurrence of this deficiency, this position will be evaluated on an annual basis by the Board of Directors to decide if we are meeting the regulation of having a full-time Clinical Supervisor for every 8 counselors and counselor assistants.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on November 3, 2022, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as the trash receptacle in the rear of the building was uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to close the lids on the trash dumpster. The dumpster was emptied by the trash removal service that morning and the lids were left open as a result of the trash truck dropping the dumpster back in place. The facility is constantly checking and closing the dumpster lids but failed to close them that particular morning.
To correct this deficiency, it will be the Community Manager's job to check the dumpsters throughout the day and secure the lid if necessary.
To prevent the re-occurrence of this deficiency a staff meeting will be held to discuss the need to ensure the prevention of insects and rodents as a result of the trash not being covered. The Community Manager and the Executive Director will be responsible for ensuring lids are closed on the dumpster. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on November 3, 2022, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom or an operable soap dispenser in each bathroom. There were no operable soap dispensers in the communal restroom across from bedroom #326, the one across from bedroom #216 or the one to the left of the front entrance. The latter two communal restrooms also had no paper towels or mechanical dryers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility failed to supply paper towels or mechanical dryers and soap dispensers in each bathroom.
To correct this deficiency, paper towel holders are being installed in all bathrooms. Checking and re-stocking paper towels and soap dispensers will become a daily client chore and will be signed off by the client as having been performed every day.
To prevent the re-occurrence of this deficiency, the community manager on duty will check the chore sign-off sheet on a daily basis to be sure the chore is being performed.
In addition to checking the sign-off sheet, the community manager will check all bathrooms during his daily rounds to ensure the chore was completed and there is soap and paper towels in each bathroom
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on November 3, 2022, the facility failed to have hot water in the communal bathroom across from bedroom #216.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide hot water in the communal bathroom across from room #216.
To correct this deficiency, a new faucet is being installed to replace the broken faucet in the communal bathroom.
To prevent the re-occurrence of this deficiency, the Executive Director and the Community Manager on duty will inspect all faucets on a daily basis and report any broken handles or faucets to the Executive Director so we can have them repaired or replaced. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on November 3, 2022, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The light in the bathroom of bedroom #326 was not operable.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 3, 2021 annual licensing inspection.
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Plan of Correction
The facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times. The light in the bathroom of bedroom #326 was not operable on the morning of the 11/03/2022 inspection. We maintain these fixtures routinely and the week prior to the inspection all lights were inspected and replaced when needed. We came to find out that the occupants of the room twisted the lights out to make them inoperable so as not to disturb their sleep and this went undetected by staff because we had just gone through the entire building to make sure all lights were working.
To correct this deficiency, the bulbs were twisted back in and a warning was given to the occupants of the room not to loosen the bulbs again.
To prevent the re-occurrence of this deficiency, announcements are to be made at morning meditation addressing clients to report any inoperable equipment in the facility and not to loosen bulbs. Also, the community manager on duty will inspect all bathroom and bedroom lights as well as hallway lights and lights in all common areas, daily. If any lights are deemed inoperable, a request will be made and the lights or the fixtures will be replaced. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection on November 3, 2022, the facility failed to store the utensils in a clean enclosed area after each usage as they were in an unenclosed container in the kitchen area at 3:24 p.m., between the lunch and dinner meals.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to store utensils in a clean enclosed area after each usage as they were stored in an unenclosed container in the kitchen area between lunch and dinner.
To correct this deficiency covered containers will be purchased to store utensils in between meals. Announcements will be made daily at morning meditation stressing that all clients cooperate in storing utensils in between meals in the enclosed containers.
To prevent the re-occurrence of this deficiency, the community manager on duty, the Executive Director, and the Clinical Supervisor will inspect and ensure that all utensils are stored in a clean and enclosed container throughout each day. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on November 3, 2022, the facility failed to ensure that heaters were permanently mounted as a space heater was found in office #320.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that heaters were permanently mounted as a space heater was found in an office.
To correct this deficiency, the heater in question was removed from the facility and the counselor was warned about having space heaters in the building as the heating system is working properly.
To prevent the re-occurrence of this deficiency, a staff meeting will be held to discuss the regulation of not having space heaters in the offices. The Clinical Director and the community manager on duty will routinely inspect the facility for space heaters and remove them at once if found. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their policy related to ACA discharges of calling the Emergency Contact within twelve hours in one of one applicable record.
Client #3 was admitted on March 22, 2022 and was discharged Against Clinical Advice (ACA) on April 23, 2022. There was no documentation in the client record that the emergency contact was called.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The facility failed to follow our policy related to ACA discharges of calling the clients' Emergency Contact within 12 hours of discharge.
To correct this deficiency, a staff meeting will be held to discuss the policy of informing the client's Emergency Contact and documenting this call in the client record within 12 hours of ACA discharge. Added to the discharge plan will be an update for documenting that the Emergency Contact was called and the time the call was made.
To prevent the re-occurrence of this deficiency, the Clinical Supervisor will review and inspect updated discharge plans to ensure Emergency Contacts were informed of an ACA discharge in a timely manner |
709.28 (c) 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.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in seven records reviewed.
Client #1 was admitted on January 11, 2022 and was discharged on April 15, 2022. The record contained documentation of a letter to an attorney on January 12, 2022, to whom there was no client signed consent to release information form.
Client #2 was admitted on June 13, 2022 and was discharged on August 15, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on June 13, 2022, to whom there was no client signed consent to release information form.
Client #3 was admitted on March 22, 2022 and was discharged on April 23, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on March 22, 2022, to whom there was no client signed consent to release information form.
Client #4 was admitted on December 29, 2021 and was discharged on February 14, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on December 29, 2021, to whom there was no client signed consent to release information form.
Client #5 was admitted on August 23, 2022 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on August 23, 2022, to whom there was no client signed consent to release information form.
Client #6 was admitted on September 30, 2022 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on October 3, 2022, to whom there was no client signed consent to release information form.
Client #7 was admitted on September 21, 2022 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on September 21, 2022, to whom there was no client signed consent to release information form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to obtain an informed and voluntary consent from the clients for the disclosure of information concerning an attorney for a client and lab work at the diagnostic laboratory.
To correct this deficiency, a staff meeting will be held, to discuss the need to obtain an informed and voluntary consent from all clients for anyone or any entity that is seeking information on clients. This includes attorneys, probation officers, or anyone. Also, consent to release information forms will be updated for the clients to sign at intake informing them that we use a diagnostic laboratory for urine screens. Active clients will begin to sign informed and voluntary consents to release information updated forms starting December 02, 2022
To prevent the re-occurrence of this deficiency, the Clinical Supervisor will update forms and hold regularly scheduled clinical staff meetings to discuss the need to protect the clients' information through the use of signed consent to release information forms
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of seven client records, the facility failed to document that the client was notified in writing of a decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client #2 was admitted on June 13, 2022 and was administratively discharged on August 15, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document that the client was notified in writing of a decision to involuntarily terminate the client's treatment at the project.
To correct this deficiency, a staff meeting will be held to discuss the need to inform the clients in writing of any decisions to administratively discharge them.
To prevent the re-occurrence of this deficiency, the client who is being administratively discharged will be informed both in person with a member of the treatment team and in writing with a description of the offense for which he is being discharged. This document will be signed and entered into the client chart documenting the discharge. The Clinical Supervisor will check all documents leading up to the administrative discharge and will make sure the document notifying the client of his offense is entered in the client record. |