INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 19, 2023 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:
|
Plan of Correction
|
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed in three out of eight records reviewed.
Client #2 was admitted on June 20, 2023 and was still active at the time of the inspection. A release of information form was signed and dated on June 20, 2023 to probation did not include the specific information to be disclosed.
Client #4 was admitted on June 23, 2023 and was still active at the time of the inspection. Three release of information forms were signed and dated on June 23, 2023 to family members did not include the specific information to be disclosed.
Client #5 was admitted on December 10, 2022 and was discharged on March 10, 2023. A release of information form signed and dated December 10, 2022 to a government agency did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed
To correct this deficiency, the consents for these clients were remade and resigned by the client and their counselor to specify the information that was being released to coordinate the proper care.
To prevent the reoccurrence of this deficiency, the informed and voluntary consents have been reworded and redesigned to eliminate broad terms and use more individualized options for sharing client information with outside resources.
The clinical director and intake coordinator will monitor the informed voluntary consents to ensure that they are client-specific and being filled out the correct way. |
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.
|
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 three out of eight 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 June 8, 2023 and was still active at the time of the inspection. A case consultation was completed on August 11, 2023 and the next one was due no later than September 11, 2023; however, none was completed.
Client #7 was admitted on May 1, 2023 and was discharged on June 12, 2023. No case consultations were completed.
Client #8 was admitted on January 20, 2023 and was discharged on May 3, 2023. No case consultations were completed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The facility failed to document a case consultation within the guidelines established by our facility's policy and procedures manual.
To correct this deficiency, the case consultation forms were filled out for the active clients and the case consultation forms were updated to include both Case Consult forms and Treatment Plan Update forms. The clinical supervisor will go through all of the files to ensure that these forms are updated to include to correct documentation.
To prevent a reoccurrence of this deficiency, the clinical supervisor and counselor will check Treatment Plan updates and Case Consult forms at the bi-weekly staff meeting.
|