INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4-5, 2017, by staff from the Division of Drug and Alcohol 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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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 an inspection for the physical plant conducted during the onsite inspection, the facility did not have all of the required items in its bathrooms.
The two toilet rooms, and the shower rooms in section 100 of the facility, did not have mirrors in them.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Based on inspection of the toilet rooms and the shower room in the 100 section. There are no mirrors in these rooms. To correct this deficiency mirrors were purchased on 12/18/2017 and secured to the walls on this same date in the toilet and shower rooms.
To prevent a reoccurrence of this deficiency the Executive Director and quality assurance coordinator will periodically check all toilet and shower rooms to be sure that mirrors are present in these areas.
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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 an inspection of the physical plant conducted during the onsite inspection the facility failed to maintain bathroom water temperatures below 120
The hot water temperature for the shower room across from room 326 was tested at 135
The hot water temperature for the shower room across from room 216 was tested at 134 findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The water temperature in the building exceeds the maximum temperature of 120 degrees and was in fact over 130 degrees. To correct this deficiency a water temperature gauge was purchased on 12/11/2017 for the purpose of checking and maintaining a water temperature not to exceed 120 degrees.
On December 11, 2017, the water heaters were adjusted and reset to lower than 120 degrees by the Executive Director and are being monitored daily to be sure the temperature does not exceed 120 degrees.
To prevent reoccurrence of this deficiency the Executive Director and Quality Assurance Coordinator will continuously check the temperature of the water throughout the year to be sure it is not exceeding 120 degrees.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of facility records conducted during the onsite inspection, and interviews with staff, the facility's last sleeping hour fire drill was held on 04/11/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Although the facility performed two overnight fire drills within the calendar year they were not within the six month time frame necessary to meet the DDAP regulation but were seven months apart:
To correct this deficiency bi-annual fire drills during sleeping hours will be conducted no greater than 6 months apart. The facility conducted an overnight fire drill on 12/15/2017 to bring the facility into compliance with the regulation
Fire safety.:
705.10. Fire safety. (d) Fire drills. The residential facility shall: (5) Conduct a fire drill during sleeping hours at least every 6 months.
To prevent reoccurrence of this deficiency, the Executive Director and Quality Assurance Coordinator will monitor the Fire Drill Log monthly to prevent the overnight fire drill from going beyond the six month time frame.
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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 client records conducted during the onsite inspection, the facility failed to include all of the required documentation on its signed consent to release information forms.
The facility uses consent to release information forms that include 2 separate and distinct funding sources that each have a space for them to be marked as the recipient of the information to be released.
Client #1 had a signed consent to release information form dated 7/26/2017, but neither of the 2 funding sources on the release was identified as recipient of the information to be released.
Client #2 had a signed consent to release information form dated 09/27/2017, but neither of the 2 funding sources on the release was identified as recipient of the information to be released.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Intake Coordinator failed to check mark the Consent to Release Information form identifying the funding source which the client is associated. To correct this deficiency, the Consent to Release Information form will be updated, individualizing the proper funding source for identification. This will allow for only the proper consent to be used for identification.
To prevent reoccurrence of this deficiency, the Intake/Quality Assurance Coordinator will be sure to use the proper consent identifying the funding source during the admission process. The Executive Director and Quality Assurance Coordinator will also perform biweekly reviews of current files to check for any necessary updates or discrepancies in the client files.
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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 client records conducted during the onsite inspection, the facility failed to document that it notified clients of the reason for involuntarily discharging clients in 1 of 3 records reviewed.
Client #1 was admitted for treatment on 07/31/2017, and was discharged on 08/31/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Although the Intake Coordinator had client #175 sign an Intent to Involuntarily Discharge from Treatment with all the possible violations and administrative reasons why the client may be discharged from treatment, the counselor failed to notify the client #175 in writing the reason for discharge and have the client sign and date the notification.
To correct this deficiency, the counselor will use the 72 hour Notification of Termination form in the event of the client being discharged involuntarily, stating specifically in language that the client understands the reason for discharge and will be both signed and dated by the counselor and the client. If a plan of correction is in order at this time, this also needs to be noted on the form.
To prevent reoccurrence of this deficiency, the Primary Counselor and Executive Director will review the termination process with the client to be sure that proper notification of reasons for termination are being communicated with the client and documented properly as well as signing and dating the notification.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of facility records and staff interviews conducted during the onsite inspection, the facility failed to document physical exams in 2 of 7 client charts reviewed.
Client #1 was admitted for treatment on 07/26/2017, and was an active client at the time of the onsite inspection.
Client #3 was admitted for treatment on 07/31/2017, and was discharged on 08/31/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
A review of Client #1 and Client #3 files, both clients were seen by the Medical Director because other factors including prescriptions were filled for the clients. However, Clients #1 & 3 did not have documentation of their physical exams having been done. Client 3 was discharged before the inspection on Dec 4 and 5, 2017. Client #1 however, was an active client at the time of the inspection but discharged before we were able to have him seen by our Medical Director. To correct this deficiency, client files will be presented to the Medical Director upon admission and documentation of the physical exam will be performed. A check list will be developed and used by the Intake Coordinator for the purpose of making sure all Client files have their Physical Exams performed, documented, signed by MD and dated.
To prevent a reoccurrence of this deficiency the Executive Director and the Intake/Quality Assurance Coordinator will conduct weekly reviews of the Client files to be sure the physical exams are being performed, documented, signed by the Medical Director and dated.
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