INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4, 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 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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704.6(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 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. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their close supervision, in one of one applicable record reviewed.
Employee # 5 was hired as an Associates ' s level counselor assistant by the facility on June 20, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the weekly close supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their close supervision.
To correct this deficiency, documentation describing the direct supervision of a counselor assistant will be used. Although the counselor assistant is supervised through direct observation, the supervision notes have to be specific in describing the CA direct supervision.
To prevent the re-occurrence of this deficiency, the Clinical Supervisor will review the supervision notes to ensure the description of the direct supervision for the particular week. The clinical supervisor will advise the supervisor of any revision needed in the supervision notes describing the direct observation on a weekly basis. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and CPR certifications provided by the facility, the facility failed to ensure that at least one person with current CPR certification was onsite during the project's hours of operations. The following shifts did not have staff with current CPR certification:
9/21/22 - 11:00 p.m. - 7:00 a.m.
9/22/22 - 11:00 p.m. - 7:00 a.m.
9/28/22 - 11:00 p.m. - 7:00 a.m.
9/29/22 - 11:00 p.m. - 7:00 a.m.
10/5/22 - 11:00 p.m. - 7:00 a.m.
10/6/22 - 11:00 p.m. - 7:00 a.m.
10/9/22 - 11:00 p.m. - 7:00 a.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that at least one person with current CPR certification was onsite during the project's hours of operations
To correct this deficiency, the project will have to get new hires CPR certified ASAP. If the CM on duty has no CPR certification, he or she will work with another community manager who is certified in CPR until the employee becomes certified in CPR.
To prevent the re-occurrence of this deficiency, the Clinical Supervisor, and the Executive Director will review monthly, the CPR training needs of the project and will arrange to have all shifts covered by staff that are CPR certified. |
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 two of two applicable records reviewed.
Client #1 was admitted on March 2, 2022 and was discharged Against Clinical Advice (ACA) on April 9, 2022. There was no documentation in the client record that the emergency contact was called.
Client #2 was admitted on June 23, 2022 and was discharged Against Clinical Advice (ACA) on July 21, 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 one record reviewed.
Client #4 was admitted on May 25, 2022 and was discharged on August 13, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on May 25, 2022, with no client signed consent to release information form signed by the client.
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 The Pa Dept of Human Services, 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 |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the name, agency or organization to whom disclosure is made in one record reviewed.
Client #1 was admitted on March 2, 2022 and discharged on April 9, 2022. The record contained a consent to release information form signed by the client on March 2, 2022, that was missing the name, agency, or organization to whom disclosure was to be made.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that consent to release information forms included the name, agency, or organization to whom disclosure is made.
To correct this deficiency, the blank Consent to Release Information form in the client file at intake will be removed from the intake paperwork so the client is not signing a blank Consent to Release Information form by accident during intake.
To prevent the re-occurrence of this deficiency, the clients' counselor will review all consent to release information forms to be sure the clients did not sign a blank consent form.
The Clinical Supervisor will check all files biweekly to ensure that no blank consent to release information forms were signed inadvertently |
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 #3 was admitted on June 6, 2022 and was administratively discharged on June 22, 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. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of client records, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel onsite.
There was documentation of police and EMT personnel at the facility on July 20, 2022; however, there was no documentation that a written unusual incident report was filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project failed to file a written unusual incident report with the DDAP within three days following an unusual incident involving the presence of police, fire, or ambulance personnel onsite.
To correct this deficiency a staff meeting will be held to discuss the issue of unusual incidents. An unusual incident report form will be filled out in the event of any incident involving police, fire, or ambulance personnel onsite. This form will be given to the clients' counselor who will pass it along to the Executive Director. At this time the Executive Director will fill out an official DDAP Unusual Incident Report form and forward it to the DDAP within three business days of the unusual incident.
The particular Unusual Incident Report for the unusual incident that occurred on July 20, 2022, will be filed with the DDAP on Dec. 06, 2022.
To prevent the re-occurrence of this deficiency, all unusual incidents will be documented in the daily record on the Community Manager's desk, and the Community Manager on duty will fill out the Unusual Incident Report form in the Community Manager's desk. This filled-out report will be forwarded to the particular client's Counselor on the next business day and the Counselor will forward this to the Executive Director for the official report of the Unusual Incident.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in one of three applicable client records reviewed.
Client #2 was admitted on June 23, 2022 and was discharged on July 21, 2022. There was no documentation of follow-up information in the record as of the date 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 maintain a complete
client record, which is to include follow-up information.
To correct this deficiency, a staff meeting will be held to discuss our follow-up policy. No matter what we may assume about a former client or even if we know she has been placed in another facility or possible incarceration, we as a facility will still follow up and document our findings about the client.
To prevent the re-occurrence of this deficiency, the Clinical Supervisor will review all discharges on a biweekly basis to ensure that follow-ups are being performed and the findings are being documented. |