INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2018 of The Retreat at White Birch 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 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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709.32 (c) 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:
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Observations
Based on a review of seven client records and interviews with facility staff, the facility failed to document if the clients received their medications or why they did not in the Medication Administration Record (MAR) in four of seven records reviewed.
Client #2 was admitted on 8/14/18 and was still active at the time of the inspection. The facility failed to provide documentation of client receiving prescribed medication of Seroquel 200 mg daily on August 28th and 29th, 2018. During the month of September, 2018, facility documentation showed the client only received the prescribed Seroquel 200 mg daily on the 1st, 2nd, 7th, 8th, 15th and 22nd. There was no documentation on why the patient was not receiving the medication as prescribed.
Client #3 was admitted on 1/31/18 and discharged on 5/1/18. The facility documentation showed the client only received the prescribed medication of Prilosec 40 mg twice daily on February 1st, 8th, 9th, 10th, 13th, 14th, and 18th. There was no documentation as to why the patient did not received the medication as prescribed.
Client #4 was admitted on 2/28/18 and discharged on 5/28/18. The facility failed to provide documentation of client receiving prescribed medication of Prednisone 5mg on April 18th, 2018. Prednisone was prescribed for fourteen days, April 16th through April 29th, 2018. Documentation showed medication was only given for thirteen days, April 16th through April 28th, minus the missing documentation for April 18th, 2018. In addition, this client's medication administration record failed to show documentation of Dulera Aer 200-5mcg 2 puffs daily being administered for the PM dose on April 10th, 2018. Additionally, there was no documentation of a MAR for the month of March, 2018.
Client #6 was admitted on 1/5/18 and discharged on 4/4/18. There was no documentation of any prescribed medication being given during the client's stay at the facility. The facility stated that the client was on medications and acknowledged that there was no Medication Administration Record for the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training was held on 11/01/2018 for all facility staff involved with procedures for dispensing medications and documentations of all medications whether the client took the medication or not. An updated Refusal of Medication form was entered into the Medication Administration Record(MAR). The training involved documenting all prescribed medication taken by the clients or not taken and the reason why the medication was missed.
Proper documentation of MARs was implemented for all active clients following the training. The director will review MARs on an ongoing basis to ensure continued compliance.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.
Client #2 was admitted on 8/14/18 and was still active at the time of the inspection. A treatment plan update was completed on 8/16/18 and the next update was due no later than 9/16/18; however, there was no update documented in the record at the time of the inspection.
Client #3 was admitted on 1/31/18 and discharged 5/1/18. A treatment plan update was completed on 2/1/18 and the next update was due no later than 3/2/18; however, there was no updates documented in the record at the time of the inspection.
Client #5 was admitted on 8/7/18 and was still active at the time of the inspection. A treatment plan update was completed on 8/9/18 and the next update was due no later than 9/9/18; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training was held on 11/01/2018 for staff explaining the importance of completing treatment plan updates within the regulatory timeframes.
Treatment plan updates were completed for clients #2 & 5. Treatment plan updates will be completed as per the regulatory timeframes for all clients moving forward.
The director will review client records on an ongoing basis to ensure continued compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staff Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #4's employee record.
Employee #4 was hired as a counselor on July 27, 2016 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2017 through December 31, 2017. Employee #4's employee record only contained documentation verifying 19.7 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff were reminded of the minimum number of training hours that must be completed during the training year. Employee #4 will complete a minimum of 25 hours of training during the 2018 training year.
The director will review employee training hours on an ongoing basis to ensure continued compliance.
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