INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6-7, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form on November 6-7, 2019, the facility failed to ensure that employee's #3, 6 and 7 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was employed as support staff on May 1, 2017 and promoted to counselor assistant on December 1, 2017. Employee was due to have the communicable disease trainings no later than December 1, 2018. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #6 was hired as a support staff/driver on July 11, 2016 and was due to have the communicable disease trainings no later than July 11, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD training as of the date of the inspection.
Employee #7 was hired as an office manager on July 6, 2016 and was due to have the communicable disease trainings no later than July 6, 2018. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility failed to ensure that staff was trained a minimum of 6 hours in HIV/AIDS and a minimum of 4 hours in TB/STD and other health related topics within the regulatory timeframe.
To correct this deficiency, all clinical and support staff that have not been trained in these areas will be trained in the next available trainings in these areas.
To prevent re-occurrence of this deficiency, the Executive Director will review training binder on a monthly basis to ensure that all employees are trained in these areas within the regulatory timeframe. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection conducted on November 7, 2019, it was observed that the facility failed to maintain furnishings in a state of good repair. On the front porch lounge area used by clients, a chair had a broken seat deeming it unsafe to be used.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to maintain furnishings in a state of good repair, having a broken chair on the front porch of the facility.
To correct this deficiency, the chair was removed from the front porch on 11/07/2019 and was put in the dumpster.
To prevent re-occurrence of this deficiency, all furniture will be inspected by Executive Director daily. Weekly staff meetings that are held will touch on this subject with all employees to be aware of furniture in disrepair that need to be removed from the premises promptly. |
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 a physical plant inspection on November 7, 2019, the facility failed to maintain hot water temperatures at or below 120 F. The bathroom hot water in the 300 hallway registered at 132. 2F. The hot water in the bathroom in the 200 hallway registered at 129.9.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility failed to maintain hot water temperatures at or below 120 F. To correct this deficiency, the water heater was reset to 120 degrees F on 11/07/ 2019. To prevent reoccurrence of this deficiency, locks will be installed on the closet containing the water heater. The Executive Director will check the water temperature on a daily basis to keep the facility within the regulation. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the facility's policy and procedure manual at the outpatient facility on October 8-9, 2019, the facility failed to develop and implement a policy and procedure to address selling or use of illicit drugs on the premises
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has no policy and procedure to address selling or use of illicit drugs an the premise.
To correct this deficiency, a policy and procedure will be developed and entered into the policy and procedure manual. Then we shall use the policy and procedure addressing selling or using illicit drugs on the premises should this action take place.
To prevent re occurrence of this deficiency, the Executive Director will create the necessary policy and procedure. The Executive Director will conduct an in house training with all Outpatient staff to introduce the new policy and procedure addressing selling or using illicit drugs on the premises. The staff will be expected to implement and follow the newly updated policy and procedure should events call for action. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the facility's policy and procedure manual at the outpatient facility on October 8-9, 2019 , the facility failed to develop and implement a policy and procedure to address theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Policy and Procedure manual has no policy and procedure to address theft, burglary, break-in or similar incident at the facility. To correct this deficiency, the Executive Director will develop a policy and procedure addressing theft, burglary, break-in or similar incident at the facility.
To prevent re occurrence of this deficiency, the Executive Director will introduce the newly updated policy and procedure to the staff at an in-house training and the expectation that all staff will implement the new policy and procedure addressing this deficiency. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's policy and procedure manual at the outpatient facility on October 8-9, 2019, the facility failed to develop and implement a policy and procedure to address an event at the facility requiring the presence of police, fire or ambulance personnel
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our policy and procedure manual failed to develop and implement a policy and procedure to address an event at the facility requiring the presence of police, fire or ambulance personnel. To correct this deficiency, the Executive Director develop a policy and procedure addressing this deficiency.
To prevent re occurrence of this deficiency, an in-house training with all staff will be conducted by the Executive Director introducing the new policy and procedure and the implementation of the new policy and procedure by all staff. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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
Based on a review of client records on November 6-7, 2019, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in five charts reviewed.
Client #1 was admitted on August 22, 2019 and was still active at the time of the inspection. The preliminary treatment plan, dated August 22, 2019, stated individual sessions weekly. The comprehensive treatment plan did not state frequency for individual sessions. The client did not receive individual sessions between August 24-September 5, September 7-19, September 21-October 3, October 5-17, and October 19-31, 2019.
Client #2 was admitted on August 27, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated August 28, 2019, stated weekly group therapy sessions. The client did not receive group sessions between September 7-18, September 21-October 2, October 19-October 31, 2019.
Client #3 was admitted on September 16, 2019 and was still active at the time of the inspection. The treatment plan, dated September 16, 2019 stated biweekly individual and weekly group sessions. There were no documented individual sessions after October 14, 2019 and no documented group sessions after October 16, 2019.
Client #4 was admitted on March 6, 2019 and discharged on June 6, 2019. The treatment plan dated March 6, 2019, stated individual and group sessions weekly. The client did not receive individual sessions between March 9-21, March 23-April 11, April 13-25, April 27-May 9, May 11-23, and May 25-June 4, 2019.
Client #7 was admitted on June 4, 2019 and discharged on September 1, 2019. the treatment plan dated June 7, 2019 stated bi-weekly individual sessions and weekly group sessions. The client did not receive individual sessions between June 8-27, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide documentation that the clients received counseling services according to their individual treatment plans.
To correct this deficiency and bring the facility into compliance with the regulation, proper documentation of client participation in these required counseling services with proper times and dates will be entered into the client files. If not, an explanation of why these clients did not receive the required counseling services will be entered into the files.
To prevent re-occurrence of this deficiency, the client files will be monitored on a biweekly basis. The Executive Director will be responsible for performing the biweekly monitoring of the client files to ensure the facility remains in compliance with the regulation
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