INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24-25, 2024 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 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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705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conduced on September 25, 2024, the facility failed to limit smoking to designated smoking areas. A tin can full of cigarette butts as well as cigarette butts scattered on the ground were observed outside an exit door, labeled "NON SMOKING AREA."These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to limit smoking to designated smoking area when a can and cigarette butts were found in an area deemed non-smoking.
To correct this deficiency, the area will be deemed a designated smoking area.
To prevent reoccurrance of this deficiency the non-smoking area sign will be removed and a smoking permitted sign will replace it. The Clinical Supervisor, Executive Director, The counselors and all community managers on duty will monitor that the clients are only smoking in designated smoking areas. |
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 client records, the facility failed to follow their policy to notify the emergency contact of the client leaving the facility against medical advice in one out of six records reviewed. Client #4 was admitted on May 21, 2024 and left against medical advice on June 28, 2024. There was no documentation in the client record that the emergency contact was notified within twelve hours. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to follow our own policy about notifying emergency contact of the client leaving the facility against medical advice.
To correct this deficiency, a staff meeting will be held by the Clinical Supervisor, explaining to the clinical staff that our policy is to contact the emergency contact within the first twelve hours.
To prevent reoccurrance of this deficiency, the Clinical Supervisor will review files with the counselors and counselor assistants to ensure the policy is being followed. Also, the clinical supervisor will reinforce the policy of contacting the emergency Contacts within the first twelve hours at our regular weekly staff meetings. |
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, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one out of six records reviewed. Client #1 was admitted on May 24, 2024 and was still active at the time of the inspection. A release of information form signed by the client and dated May 24, 2024 failed to include the name of the person, agency or organization to whom disclosure is made.This finding was reviewed with the facility during the inspection process.
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Plan of Correction
The facility failed to obtain informed and voluntary consent from a client by having the client sign and date a blank consent form.
To correct this deficiency, any blank consent to release information forms will be removed from the master client chart program in the intake office.
To prevent reoccurrance of this deficiency, counselors and intake/admission staff will be trained at an in-house staff training with the Clinical Supervisor, to ensure that all blank consents are not in the client record. Clinical Supervisor will inspect client records weekly to be sure that no blank consents are in the record. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facilty failed to ensure that informed and voluntary consent to release information forms contained dated signature of client in two out of six records reviewed. Client #1 was admitted on May 24, 2024 and was still active at the time of the inspection. The record contained a consent to release information dated May 24, 2024, which failed to include the name of the person, agency or organization to whom disclosure is made, with client's signature but no date. Client #3 was admitted on May 10, 2024 and was still active at the time of the inspection. The record contained a consent to release information for a funding source that was neither signed nor dated 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 ensure that informed and voluntary consent to release information forms contained dated signatures of clients.
To correct this deficiency, the clinical supervisor will meet with the intake/admission coordinator to reinforce the need to check and double-check that all informed and voluntary consent to release information forms are signed and dated by the client at admission.
To prevent reocuurance of this deficiency, the intake/admission coordinator, the counselors, and counselor assistants will be trained by the clinical supervisor at an in-house training on making sure the consents are signed and dated during the initial contact with the clients. The clinical supervisor will be responsible for reviewing the client records on a weekly basis; checking that all consents are signed and dated. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on the review of medication adminstration records, the facility failed to document the adminstration, or the reason a medication was not adminstered in four out of six applicable records. Client #1 was admitted on May 24, 2024 and was still active at the time of the inspection. He was prescribed Buprenorphine 1mg film 2x daily. There is no documentation for the medication being adminstered or the reason not adminstered two times on August 27, 28,30, and 31. He was also prescribed Melatonin 5mg at bedtime. There was no documentation for the medication being adminstered or the reason not adminstered for August 1-31, 2024. Client #2 was admitted on July 2, 2024 and still active at time of the inspection. He was prescribed Suboxone film 2mg 1 film 2 times daily. There is no documentation of the medication being administered or the reason not administered on July 5, 2024 and not being adminstered two tines on July 30, 2024. Client #3 was admitted on May 10, 2024 and still active at time of the inspection. He was prescribed Suboxone 2mg film 2x daily. There is no documentation for the medication being adminstered or the reason not being adminstered two times on June 1, 2, 3, 4, 5, 6, 7, and 9, 2024. He was prescribed trazadone 300 mg at bedtime. There is no documentation for the medication being adminstered or the reason not being adminstered on May 31, 2024. Client #6 was admitted on April 4, 2024 and discharged on July 3, 2024. He was prescribed Levetipiacote 500 mg 1 tab 2x daily. There is no documentation of the medication being adminstered or the reason being adminstered two times on June 6, 7, 11, 13, 14, 15, 19, 20, 21, 25, 2024. There is no documentation of the medication being adminstered or the reason being adminstered on June 8, 12, 26, 27, 29, and 30, 2024. He was also prescribed Topiramate 25 mg 1x daily. There is no documentation of the medication being adminstered or the reason being adminstered on June 6, 7, 8, 11, 12, 15, 19, 20, 21, 23, 24, 25, 26, 27, 29 and 30, 2024. These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The facility failed to document the administration or the reason a medication was not administered
To correct this deficiency, the facility will just mark the MAR when the client administers his or her medication or does not administer his or her medication. The missed medication sheet will be eliminated. If the client does not show or refuses to take the medication, the reason for the missed med will be documented directly into the MAR along with the date and time, by the staff member on duty. This will be supervised by the Clinical Supervisor.
To prevent the reoccurrence of this deficiency the MAR will be reviewed daily by the Clinical Supervisor to ensure the staff is documenting the administration of meds or the non-administration of meds and the reason for this missed med. The Clinical Supervisor and the Executive Director will hold a Staff training concerning the documentation of the administration of meds and the documentation of missed meds on Oct 30,2024. The Clinical Supervisor will be responsible for monitoring the MAR on a daily basis and will hold weekly staff meetings discussing the topic of documenting the MAR properly. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in two out of six applicable records. Client #1 was admitted on May 24, 2024 and was still active at the time of the inspection. Client #3 was admitted on May 10, 2024 and was still active at the time of the inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to complete psychosocial evaluations.
To correct this deficiency, a clinical supervisor has been appointed for record review and staff training to ensure that all documents in the client records are present.
To prevent reocurrence of this deficiency, the Clinical Supervisor will hold a staff training on chart documentation on October 30, 2024. The Clinical Supervisor will hold weekly staff meetings discussing proper documentation in the client record. The Clinical Supervisor will be responsible for reviewing client records on a weekly basis. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in six out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 30 days following admission.Client #1 was admitted on May 24, 2024, and was still active at the time of the inspection. A case consultation was due no later than June 24, 2024; however, it was not completed until June 29, 2024.Client #2 was admitted on July 2, 2024 and waw still active at the time of the inspection. A case consultation was due no later than August 2, 2024; however, it was not completed until August 5, 2024.Client #3 was admitted on May 10, 2024 and was still active at the time of the inspection. A case consultation was due no later than June 10, 2024; however it was not completed until July 15, 2024.Client #4 was admitted on May 21, 2024 and was discharged on June 28, 2024. A case consultation was due no later than June 21,2024; however, it was not completed until June 23, 2024.Client #5 was admitted on March 28, 2024 and discharged on June 26, 2024. A case consultation was due no later than April 28, 2024; however it was not completed until May 2, 2024. Client #6 was admitted on April 4, 2024 and discharged on July 3, 2024. A case consultation was due no later than May 4, 2024; however it was not completed until May 8; 2024. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the September 9. 2023 annaul licensing inspection.
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Plan of Correction
The facility failed to document case consultations within the guidelines established by the facility's policy and procedures manual. The facility 's policies and procedures manual states the case consultations must be completed every 30 days following admission.
To correct this deficiency, the facility's policy and procedures manual will be updated to state the case consultations must be completed every 30 days following implementation of the client's Master Treatment Plan.
To prevent reoccurrence of this deficiency, the Clinical Supervisor will review files to ensure the updated policy is being followed by all Clinical Staff . Clinical Supervisor will train and discuss expectations of the counselors concerning the updated Policy during weekly clinical staff meetings. |