INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted September 30, 2024 - October 1, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
The facility failed to ensure the retention of client records for a minimum of four years following the discharge of a client as evidenced by the following:Six client records were requested to review during the investigation. One record was unable to be located. The missing record was for client #6 who was admitted on 2/6/2024 and discharged on 3/9/2024.
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Plan of Correction
The facility failed to ensure the retention of records for a minimum of four years following the discharge of a client when a client record could not be located.
To correct this deficiency, when the counselor finalizes the client record after discharge the counselor will hand the closed file to the Clinical Supervisor for review to be sure everything necessary is entered into the record. Once the Clinical Supervisor has completed the review and deems the record complete the file will be delivered to the Controller to be filed in a locked, safe, dry storage room. Administration will have the keys to the storage room so all files are accounted for.
To prevent further reoccurrence of this deficiency, a clinical staff meeting will be held by both the Executive Director and the Clinical Director to inform clinical staff of procedures to follow to ensure retention of client files according to regulations.
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709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
The facility failed to ensure the security of client medication including, but not limited to, the loss, theft or misuse of drugs as evidenced by one of five charts reviewed. Client #1 was admitted on March 20, 2024 and discharged May 13, 2024. The Controlled Drug Received Record/Disposition Form showed that the client was admitted with 22 Suboxone films. However, the Medication Administration Record (MAR) began with 4 suboxone films. Then it jumps from 0 films on 3/22/24 to 14 films. On 3/29/24 goes from 0 films to 4 films. On 3/31/24 0 films and 4/1/24 0 then 11 films. On 4/5/24 4 films remaining, next page list 4/5/24 as 14 films remaining. On 4/9/24 only a half of a film was taken. On 4/12/24 14 films were added and the end of the MAR page lists 13 films remained after client received 1 film at 3 pm on 4/12/24. 4/12/24 lists 13 films. On 4/19/24 0 films are listed. The next page lists 15 films on 4/19/24. Then the MARs two different dates on the same page: 4/24/24 and 5/25/24 twice and 5/26/24 in which it shows 1 film given AM and PM on 5/25 and 1 suboxone film given in AM on 5/26 but the number remaining is 2 suboxone films for both. Then the MARs starts with 23 suboxone films on 4/29/24 in PM. The next page of the MARs starts on 5/3/24 with 16 suboxone films and goes through 0 on 5/11/24. Starts with 3 suboxone films on 5/10/24 through 0 on 5/13/24.There was no documentation explaining the discrepancies in the medication counts.
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Plan of Correction
The facility failed to ensure the security of the client medication including but not limited to, the loss, theft or misuse of drugs. The MAR was not being monitored properly by staff and discrepancies were discovered.
To correct this deficiency, the MAR was updated to start with the original count during admission to the program. If the medication is a controlled substance, the controlled substance will be stored in a safe in the Administration Office according to our policy. This policy was updated to have the safe now stored in the administrative office instead of the Med Room. A separate MAR in the Administrative Office records the original amount of meds and adds or subtracts as the client is using the meds or the pharmacy is delivering the meds. The MAR in the Administrative Office will be monitored daily by the Clinical Supervisor. The Clinical Supervisor will monitor the MAR in the MED Room on a weekly basis to ensure the med counts are accurate. As the Controlled substances are being added to the med cart by the Clinical Supervisor for availability to the client the MAR is updated by the Clinical Supervisor and updated at the med cart.
The MAR for meds at the med cart is being updated to account for the meds left over from admission plus meds that are being delivered by the pharmacy to give us a running count as the meds are replenished for the individual client. This could be verified by the pharmacy delivery sheet , the surrender sheet and the amount the client has taken to date. This verification of the meds and the counts will be the responsibility of the Clinical Supervisor.
To prevent reoccurrence of this deficiency, the Clinical Supervisor will monitor the med counts weekly in the MAR and compare them to the actual med counts to ensure the security of client medication. The Clinical Supervisor, Executive Director and the Controller along with Counselors and all staff will meet weekly to discuss facility policies including but not limited to the security of client medication. All staff will be trained on proper procedures for documenting medication counts at the weekly staff meeting. The Clinical Supervisor will be responsible for training the staff and ensuring the policy is being followed.
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