INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 1-2, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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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 the facility's Program Completion Discharge policy and a review of client charts, the facility failed to follow their policy in two out of four applicable charts as evidenced by:
The facility's policy indicates that program completion is determined by the client's progress of their treatment plans goals and objectives. There was no documentation of the client's achieving their treatment plan goals or objectives prior to completing treatment.
Client #1 was admitted on 10/5/2023 and discharged on 5/15/2024. The last individual counseling on 4/24/2024 indicated that the client was to continue to attend one individual session and one group per week. The discharge summary dated 5/17/2024 indicated that the client completed treatment. However, there was no documentation of the client's treatment plan goals or objectives being achieved.
Client #5 was admitted on 6/6/2024 and discharged on 9/11/2024. The last individual counseling on 8/21/2024 indicated that the client was to continue weekly individual and group sessions. The discharge summary dated 9/11/2024 indicated that the client completed treatment. However, there was no documentation of the client's treatment plan goals or objectives being achieved.
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Plan of Correction
The facility failed to follow our own Program Completion Discharge Policy by not documenting the clients achieving their treatment plan goals or objectives prior to completing treatment.
To correct this deficiency, there will be a staff training on documentation for Program Completion and stating if the client achieved his or her treatment plan goals or not, using the Policies and Procedures already in place at the facility.
To prevent reoccurrence of this deficiency, a clinical supervisor has been promoted to supervise at the Outpatient Facility. The clinical supervisor will conduct weekly record reviews to ensure the required documentation has been entered into the record by the clinical staff which is individualized and descriptive.
Also, the Clinical Supervisor will review charts and individual cases with the counselors on a weekly basis, to ensure that all necessary treatment is taking place, and the proper documentation is being used when discharging clients stating whether they have achieved their treatment plan goals or not, while in treatment. Also, the Clinical Director will meet with the counselor before the client is discharged to review discharge summaries and treatment plan goals that were achieved or not achieved.
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709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
Based on a review of personnel files and the facility's Supervision of Staff policy, the facility failed to ensure the supervision of staff in three out of five applicable personnel files as evidenced by:
The facility's Supervision of Staff policy indicates that staff will be evaluated after their 90 day probationary period and monthly supervision.
Employee # 2 was hired on 6/1/2023 as a Counselor Assistant and promoted to a Counselor on 6/1/2024. There were no supervisory sessions documented in the personnel file.
Employee # 3 was hired on 11/13/2023 as a Counselor. There were no supervisory sessions documented.
Employee # 5 was hired on 7/17/2023 as a Counselor and left employment on 4/22/2024. There was no documentation of a 90-day evaluation or any supervisory sessions.
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Plan of Correction
The facility failed to document the supervision of staff according to our policies and procedures regarding the supervision of staff.
To correct this deficiency, all Counselors and Counselor Assistants will be supervised and evaluated according to the policies and procedures already in place by the facility. All weekly and monthly supervision will be documented and put into the respective files.
All employees will be supervised, disciplined and evaluated by appropriate supervisor throughout the year
1) Promotions, leaves (vacation, bereavement, personal, sick time) will be approved by employee supervisor
2) Training will be required by all employees at the direction of immediate supervisor
3) Employee grievances will be handled by immediate supervisor
4) Annual evaluations will be conducted by immediate supervisor
5) Employees will meet with Executive Director and Clinical Supervisor bi-weekly throughout the year for supervision and evaluation
6) Employees will be disciplined throughout the year by immediate supervisor and supervisor will follow progressive disciplinary policy for infractions against
Documentation of this supervision including 90 day and annual evaluations of the employees will be placed in the respective employee files by the Clinical Supervisor.
To prevent the reoccurrence of this deficiency, a Clinical Supervisor has been recently appointed to the Outpatient Facility and he along with the Executive Director will use the policies and procedures in place to ensure that the regulations regarding employee supervision are being followed. The Clinical Supervisor will document all supervision meetings and enter the documentation into the employee files. The Executive Director will conduct monthly audits of the personnel files to ensure the employee supervision is documented.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of facility policies along with staff interviews and the observation of a video, the facility failed to maintain client confidentiality. A client was recorded by the facility director while at the hospital. In addition this video was shared amongst facility staff.
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Plan of Correction
The facility failed to maintain client confidentiality when a client was recorded by the Executive Director while at the hospital and the video was shared among an employee of the facility.
To correct this deficiency, a written procedure has been developed by the project director to comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented Information). The procedure includes but is not limited to (1) Confidentiality of client identity and records. The procedures include a description of how the project plans to address security and release of electronic and paper records and identification of the persons responsible for maintenance of client records. This is found in our Policies and procedures manual.
Also there will be a staff training on confidentiality and the need for us as an agency not to get too close or connected to clients and former clients through electronic communication, texting, phone calls, videos, social media, etc.
This staff training will include a staff review of
Confidentiality of Client Identity and Records §709.28(a)(1)
Found on pgs 29-27 of the Policies and Procedures Manual
To prevent reoccurrence of this deficiency, agency wide biweekly staff meetings will include addressing confidentiality and boundaries that we should not cross with clients and former clients by following the Policies and Procedures of The Retreat at White Birch.
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of the Client's Rights, staff interviews and the observance of a video, the facility failed to follow its Client Right policy.
The facility Client Rights indicate clients are to be treated with courtesy, dignity, and respect. They are to be protected by professional ethics and standards.
A client was recorded by the facility director while at the hospital and derogatory remarks could be heard spoken by the facility director toward the client. In addition, it was reported this video was shared amongst facility staff.
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Plan of Correction
The facility failed to follow our Client's Rights Policy. The Executive Director stepped across a professional boundary by making a derogatory remark to a client while the client was in the hospital and recorded the remark. This remark was shared with another staff member.
To correct this deficiency, the Executive Director and all staff will attend an in-house training where Client Rights and Client Expectations will be reviewed and discussed. In this training we will discuss Client Rights 709.30 in The Retreat at White Birch Policies and Procedures Manual and our statement on client rights found in the Client handbook.
CLIENT'S RIGHTS
As a client of The Retreat at White Birch you have the right to:
1. Be treated with courtesy, dignity, and respect.
2. Be told of available services.
3. Know that all information about you or your treatment will be kept strictly confidential, and that no information will be released without your permission.
4. Receive skilled professional care.
5. Be protected by professional ethics and standards.
6. Take an active, responsible part in making up your treatment plan and to sign it.
7. Take an active, responsible part in carrying through your treatment plan.
8. Express complaints and grievances and to have them heard and an answer given. A copy of the Grievance Procedure follows.
9. Appeal any decisions concerning you or your treatment and to receive an answer
10. Explore and question The Retreat at White Birch programs and policies and to make suggestions.
11. Review your client file. Your counselor or the program director may remove certain information for appropriate clinical reasons.
12. Request the removal of incomplete, outdated or irrelevant information and to submit rebuttal to anything in your chart.
To Prevent reoccurrence of this deficiency, Client Rights will be part of the discussion at the Bi-weekly staff meetings held by the Clinical Supervisors. The Retreat at White Birch will follow all policies and procedures connected to protecting Client Rights.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to assure that counseling services are providing according to the individualized treatment and rehabilitation plan in two out of six charts as evidenced by:
Client #2 was admitted on 12/5/2023 and was still a client at the time of the investigation. The treatment plans dated 12/11/2023, 2/8/24, 4/4/2024, 5/30/2024, 7/24/2024, and 9/23/2024 indicated one hour of individual counseling per week. There was no documentation of individual counseling during the weeks of 1/12/204, 3/11/2024, 7/10/24, 7/17/24, 8/21/24, 9/5/24, 9/12/24, and 9/19/24.
Client #5 was admitted on 6/6/2024 and discharged on 9/11/2024. The treatment plans dated 6/10/2024 and 8/2/2024 indicated one individual counseling session per week. There was no documentation of individual counseling during the weeks of 8/26/2024 and 9/2/2024.
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Plan of Correction
The facility failed to assure that counseling services were provided according to the individualized treatment and rehabilitation plan. Although the clients failed to show for the scheduled individual counseling sessions, the counselors failed to document the client not showing up for his or her session in a case management note that should have been entered into the record.
To correct this deficiency, the newly appointed Clinical Supervisor will review files to be sure that documentation of client treatment and rehabilitation is being recorded.
To prevent reoccurrence of this deficiency, documentation of all treatment appointments, whether the client showed up or not, will be entered into the record. This will be discussed and reviewed during regular scheduled staff meetings and trainings by the Clinical Supervisor. Also, the Clinical Supervisor will review the client records weekly, to be sure the documentation is being added into the record.
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