INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16th, 2018 of The Retreat at White Birch Outpatient 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential 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
The facility failed to ensure privacy in all counseling areas. Group room 2 had a window in the door with no covering, thus allowing unobstructed visual access.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Group Room 2 has a clear glass window on the door which allows for unobstructed visual access to this room. To correct this deficiency, a window frosting kit has been purchased and is being installed on 10/30/2018 to bring the group room into compliance.
To prevent re occurrence of this deficiency, the Executive Director and Intake/Admission Coordinator will inspect all doors and windows dialy to be sure there is no visual access to group rooms.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that the water temperature did not exceed 120 degrees Fahrenheit in the bathroom. At the time of inspection, October 15 th, 2018 at 11 am the water temperature was 133.6 Fahrenheit
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility had water temperature that exceeded 120 degrees in the bathroom. To correct this deficiency, the landlord was notified of the excessive water temperature and a work order was put in to bring the water temperature down to 120 degrees.The temperature was reduced to meet the 120 degree Fahrenheit regulation on 10/30/2018 to bring the facility into compliance with the regulation.
To ensure no re occurrence of this deficiency, the Executive Director will monitor the temperature of the water on a weekly basis. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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
The facility failed to document in the fire drill logs which exit was used during the fire drill and whether the fire alarm or smoke detector was set off.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to document in the fire drill logs which exit was used during the fire drills and whether the fire alarm was set off.
To correct this deficiency,the fire drill log sheet was updated on 10/22/2018 to bring the facility into compliance.
To prevent future re occurrence deficiency, the Executive Director and Intake Coordinator will use updated Fire Drill Logs and document exits used and any problems with the fire alarms or any problems in general. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to ensure that all hard copy patient records were kept in locked storage containers and that there was no ability of unauthorized persons to gain access to such records. The facility was using an office (1st door on the left in back hallway) for the storage of files for current and discharged clients. While there was a lock on the filing cabinet, the filing cabinet was left unlocked during the day and the door to the office did not close and lock properly.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Although the facility kept the files locked and in a locked office, the locks on the door did not lock properly. To correct this deficiency, the landlord was contacted and a work order was put in place to fix the locks on the office doors in the back.
The files were removed form the office with the faulty locks and moved to an office that locks properly on 10/16/2018 bringing the facility into compliance with this regulation.
To prevent a re-occurrence of this deficiency, the Executive Director will perform a weekly inspection on all locks to make sure they are functioning properly and he will train staff at biweekly staff meetings on the importance of securing client files at all times. |
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
The facility failed to document a completed consent to release information in three of seven client records reviewed. There were forms that were missing required information.
Client #1 was admitted September 19, 2018 and was still an active client at the time of the inspection. There were two separate consent to release information forms, signed and dated September 19, 2018 without the name of the person, agency or organization to whom the release is for. In addition, there was a release signed and dated September 19, 2018 to the insurance provider that did not include the client's complete given name.
Client #4 was admitted September 4, 2018 and was still an active client at the time of the inspection. The record included three consent to release information forms all dated September 4, 2018 that did not include the client's complete given name. The forms were to an outside provider, an emergancy contact, and the Primary Care Physician.
Client #6 was admitted March 28, 2018 and discharged May 10, 2018. The record included a consent to release information form to the Primary Care Physician dated April 4, 2018 which only contained the client's first name.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility failed to fully identify the clients using their first names only on consent to release information forms. To correct this deficiency, the Executive Director held a staff meeting on 10/22/2018 to train the staff on how to properly document client information in the client files using the clients full name, bringing the facility into compliance with this regulation.
To prevent this deficiency form re-occurring, the Executive Director will perform biweekly reviews of the client files to ensure proper documentation is being used by the staff. This deficiency will also be discussed by the Executive Director and staff at all regularly scheduled staff meetings. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document the type and frequency of sessions in the comprehensive treatment plans in three of seven client records reviewed.
Client #1 was admitted September 19, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated October 2, 2018, did not include documentation of the type and frequency of therapy sessions.
Client #5 was admitted November 16, 2017 and discharged on July 9, 2018. The comprehensive treatment plan dated November 16, 2017, did not include documentation of the type and frequency of therapy sessions.
Client #7 was admitted August 16, 2017 and discharged April 30, 2018. The comprehensive treatment plan dated August 22, 2017, did not include documentation of the type and frequency of therapy sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's comprehensive treatment plans failed to document the type and frequency of therapy sessions. To correct this deficiency, the comprehensive treatment plan was updated on 10/19/2018 to include the type of therapy the individual client will be attending and the frequency of the therapy sessions.
To prevent this deficiency from re-occurring, the Executive Director will hold biweekly staff meetings to update the clinical staff on the need to document the type and frequency of the therapy sessions and the Executive Director will biweekly review client files to ensure counselors are documenting type and frequency of therapy sessions. |
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
The facility failed to complete treatment plan updates per regulatory time frames in one of three applicable client records reviewed.
Client #2 was admitted on June 5, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on June 8, 2018. The last treatment plan update was completed on August 2, 2018. The next update was due no later than October 2, 2018 ; however, there was no update documented in the record at the time of the inspection.
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Plan of Correction
The facility failed to a regularly scheduled treatment plan update on a client. To correct this deficiency, the counselors will update the treatment plans on a timely basis in accordance with the regulation.
To prevent re-occurrence of this deficiency, the Executive Director will perform biweekly reviews of the client files to ensure the counselors are updating the treatment plans in a timely manner.
The Executive Director will also hold biweekly staff meetings to discuss the importance of keeping files and treatment plans up to date. |