INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 7, 2022, 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 Outpatient 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of the Staffing Requirements Facility Summary Reports, the Project failed to have a full-time clinical supervisor for every eight Full Time Equivalent (FTE) counselors or counselor assistants.
The Project FTE is determined by adding the total number of hours each facility in the Project devotes to their clients by facility's work week. Then, if the FTE is between 8 and 15, the Project is required to have at least one full-time clinical supervisor.
The Project's FTE is as follows:
Total hours devoted to clients across the Project is 398. The Project's work week is 40 hours. The Project reported no full-time clinical supervisors. The Project's FTE calculation is as follows: 398/40 = 9.9(FTE); 9.9 counselor FTE hours requires 1 full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility failed to ensure that a full-time clinical supervisor was hired as the FTE calculation of 8 counselors was met for the project.
To correct this deficiency, a full-time clinical supervisor that meets the educational and experiential requirements has been promoted to the position.
To prevent the re-occurrence of this deficiency, this position will be evaluated on an annual basis by the Board of Directors to decide if we are meeting the regulation of having a full-time Clinical Supervisor for every 8 counselors and counselor assistants. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their close supervision, in one of one applicable records reviewed.
Employee # 3 was hired as a high school level counselor assistant by the facility on March 7, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the weekly close supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to maintain documentation that counselors' assistants receive direct observation of the provision of counseling services as part of their close supervision in employee #3's record.
To correct this deficiency, documentation will be descriptive when addressing the close observation of the counselor assistant's supervision. Although the counselor assistant is being directly observed, the supervision notes need to reflect the direct observation.
to prevent the re-occurrence of this deficiency, the Clinical Supervisor and Counselor will review on a weekly basis the supervision notes for all counselor assistants to ensure that there is direct observation and this direct observation is being documented clearly
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on November 7, 2022, the facility failed to ensure stairways from the facility were unobstructed as the stairway to the rear emergency exit was obstructed by a ladder and other items.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure the stairwells from the facility were unobstructed.
To correct this deficiency, the landlord of the building was notified by phone that we removed his ladder and other items and stored them in a spot on the second floor which is safe for all occupants of the building.
To prevent the re-occurrence of this deficiency, the Executive Director and the Clinical Supervisor will inspect stairwells in the building weekly for items obstructing the safe use of the stairwells. |
709.28 (c) 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.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three records reviewed.
Client #1 was admitted to the Outpatient level of care on November 9, 2021 and was discharged on July 15, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on November 9, 2021, with no client signed consent to release information form signed by the client.
Client #2 was admitted to the Outpatient level of care on December 13, 2021 and was discharged on January 5, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on December 13, 2021, with no client signed consent to release information form signed by the client.
Client #3 was admitted to the Outpatient level of care on January 10, 2022 and was discharged on May 26, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on January 10, 2022, with no client signed consent to release information form signed by the client. Additionally, the record contained documentation of identifying information and lab work released to a diagnostic laboratory on February 11, 2022, to whom there was no client signed consent to release information form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to obtain an informed and voluntary consent from clients for the disclosure of information. There were no releases for lab work at the diagnostic laboratory and the Pa Dept of Human Services.
To correct this deficiency, the Consent to release information forms at intake will be updated to include consent to release information for the Pa Dept of Human Services and the Diagnostic Laboratory
To prevent the re-occurrence of this deficiency, the Clinical Supervisor will review all client files biweekly to ensure that the updated intake Consent to Release Information forms containing consents for the Dept of Human Services and the Diagnostic Laboratory are signed |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of one applicable client record reviewed, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days.
Client #8 was admitted on September 29, 2020 and was active at the time of the inspection. A treatment plan update was completed on January 3, 2022 and a treatment plan update was due to be completed by February 3, 2022; however, the next treatment plan update was not completed until March 16, 2022. A treatment plan update was completed on July 8, 2022 and a treatment plan update was due to be completed by August 8, 2022; however, the next treatment plan update was not completed until September 12, 2022.
This is a repeat citation from the November 4, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that treatment and rehabilitation plans were reviewed and updated every 30 days
To correct this deficiency Clinical Supervisor and quality assurance will conduct monthly inspections of clinical files to assure that the updates are being completed on or before the scheduled date.
Also, to prevent this repeat occurrence the clinical supervisor will hold biweekly staff meetings to assure that counselor and counselor assistant files remain in compliance. |
709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that group counseling was included and documented at least twice weekly in one applicable record reviewed.
Client #8 was admitted on September 29, 2020 and was active at the time of the inspection. The record only documented a total of three group sessions for the month of September 2022 and five group sessions for the month of October 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that group counseling was included and documented at least twice weekly.
To correct this deficiency, the client will be informed by his counselor and through his treatment plan that he is to attend at least 2 group counseling sessions per week.
To prevent the re-occurrence of this deficiency, the counselors and clinical supervisor will review on a bi-weekly basis to ensure that the clients remain in compliance with treatment plans by attending the required amount of group and individual counseling sessions. |
709.83(a)(8) LICENSURE Client records
709.83. 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) Record of services provided.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project including a record of services provided in one applicable record reviewed.
Client #8 was admitted on September 29, 2020 and was active at the time of the inspection. The client record did not contain documentation of record of services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure a complete client record of service.
To correct this deficiency a paper record of service will be implemented in each client file to record the services for both group and individual counseling sessions.
To prevent a reoccurring deficiency the clinical supervisor and quality assurance will inspect client files to ensure the accuracy of the record of service in regard to the group and individual counseling sessions. The accuracy will be maintained by assuring that the billing for the client matches the record of service. Also, the record of service will reflect the lack of compliance in the client file as well. |
709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included progress notes in one applicable record reviewed.
Client #8 was admitted on September 29, 2020 and was active at the time of the inspection. The client record did not contain documentation of each individual counseling session, and instead offered a summary of multiple individual sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure a complete client record included progress notes.
To correct this deficiency, each individual session that the counselor meets with the client will be documented in the record of service and an individual note will be put in the WITS system to reflect the individual session for that date.
To prevent a reoccurrence of this deficiency the clinical supervisor will inspect the record of service for each client and ensure that there are individual counseling notes to reflect their session with the counselor. The clinical supervisor, the quality assurance coordinator, and the counselor will ensure the accuracy of the record of service and the individual notes that are entered into the WITS system.
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709.83(a)(12) LICENSURE Client records
709.83. 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:
(12) Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in one applicable record reviewed.
Client #8 was admitted on September 29, 2020 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan.
To correct this deficiency the client's treatment plan will be updated to reflect the duties and tasks they are to complete in the facility as per their level of care. Documentation through treatment plan updates will describe how performing these task are an integral part of the client's treatment and rehabilitation
To avoid a reoccurrence of this deficiency the clinical supervisor will review treatment plan updates to ensure verification of any work done around the facility is an integral part of the client's treatment and rehabilitation is documented. The counselor and Clinical Supervisor will be responsible to inspect treatment plans for the clients and ensure the accuracy and adherence of the treatment plan. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to document the frequency of treatment and rehabilitation services in their treatment plan in all seven records reviewed.
Client #1 was admitted on November 9, 2021 and was discharged on July 15, 2022. The individual treatment and rehabilitation plan completed on November 16, 2021 did not document the recommended frequency of services.
Client #2 was admitted on December 13, 2021 and was discharged on January 5, 2022. The individual treatment and rehabilitation plan completed on December 20, 2021 did not document the recommended frequency of services.
Client #3 was admitted on January 10, 2022 and was discharged on May 26, 2022. The individual treatment and rehabilitation plan completed on January 20, 2022 did not document the recommended type or frequency of services.
Client #4 was admitted on June 14, 2022 and was discharged on September 27, 2022. The individual treatment and rehabilitation plan completed on June 20, 2022 did not document the recommended type or frequency of services.
Client #5 was admitted on April 11, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on April 21, 2022 did not document the recommended frequency of services.
Client #6 was admitted on July 13, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on July 19, 2022 did not document the recommended type or frequency of services.
Client #7 was admitted on August 1, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on August 10, 2022 did not document the recommended frequency of services.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document the frequency of treatment and rehabilitation services in their treatment plan
To correct this deficiency all treatment plans will be updated to depict the level of care and the frequency of treatment and rehabilitation that each client will be responsible to adhere to.
To prevent a reoccurrence of this deficiency the clinical supervisor will be responsible to inspect all treatment plans and ensure that the level of care and the frequency of treatment is stated on each client's treatment plan. Also, the clinical supervisor will be responsible to review all treatment plans to ensure the frequency of treatment is in compliance with their level of care. |
709.93(a)(3) LICENSURE Client records
709.93. 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:
(3) Record of services provided.
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Observations
Based on a review of seven client records, the facility failed to ensure a complete client record included a record of services provided, in all seven records reviewed.
Client #1 was admitted on November 9, 2021 and was discharged on July 15, 2022.
Client #2 was admitted on December 13, 2021 and was discharged on January 5, 2022.
Client #3 was admitted on January 10, 2022 and was discharged on May 26, 2022.
Client #4 was admitted on June 14, 2022 and was discharged on September 27, 2022
Client #5 was admitted on April 11, 2022 and was active at the time of the inspection.
Client #6 was admitted on July 13, 2022 and was active at the time of the inspection.
Client #7 was admitted on August 1, 2022 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure a complete client record of services provided.
To correct this deficiency a paper record of service will be implemented in each client file to record group and individual sessions.
To prevent a reoccurrence of this deficiency the clinical supervisor will be responsible to inspect and review each client file to ensure the accuracy of each record of service for each client. The clinical supervisor will review the record of service with the counselor to ensure the accuracy of the client's record of service. |