INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4, 2021 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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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 nine client records on November 4, 2021, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one client record reviewed.
Client #5 was admitted on January 15, 2021 and was current at the time of the inspection. Client #5 had an informed and voluntary consent from the client for the disclosure of information signed and dated by the client and witness dated January 15, 2021. The facility failed to include the name of the person, agency or organization to whom disclosure may be made.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project failed to obtain an informed consent from Client #5. Upon admission, the facility had Client #5 sign and date a blank consent to release information disclosure form. To correct this deficiency, the blank consent to release information form was removed from the client file on 11/17/2021 and destroyed in the shredder.
To prevent the reoccurrence of this deficiency a staff meeting was held on 11/17/2021 to discuss the issue of signing and dating blank Consent to Release Information forms. Also, The Executive Director and the Quality Assurance Coordinator will review client files on a weekly basis to ensure that there are no signed and dated blank Consent to Release Information forms in the client files.
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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 two client records on November 4, 2021, the facility failed to document treatment plan updates within the regulatory timeframe in two out of two client records reviewed.
Client #1 was admitted on September 29, 2020 and was still active at the time of the inspection. A treatment plan update was completed on December 3, 2020 and the next update was due no later than January 3, 2021; however, one was not completed until February 11, 2021. A treatment plan update was due by March 11, 2021; however, one was not completed until March 30, 2021. A treatment plan update was due by April 30, 2021; however, one was not completed until May 3, 2021. Treatment plan updates were due by June 3, 2021 and July 3, 2021; however, one was not completed until July 12, 2021. Treatment plan updates were due by August 12, 2021 and September 12, 2021; however, one was not completed until September 22, 2021. A treatment plan update was due by October 22, 2021; however, one was not completed until November 1, 2021.
Client #2 was admitted on July 7, 2020 and was discharged on February 16, 2021. A treatment plan update was completed on November 12, 2020 and the next updates were due by December 12, 2020, January 12, 2021 and February 12, 2021; however, there were no treatment plan updates documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document Treatment Plan updates within the regulatory guidelines in two of the reviewed client records.
To correct this deficiency, the counselor will start performing treatment plan updates in the PHP every 30 days starting 11/17/2021.
To prevent the reoccurrence of this deficiency, the Executive Director and the Quality Assurance Coordinator will review client files on a weekly basis to ensure the regulation of 30-day treatment plan updates are being followed by clinical staff starting 11/17/2021
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709.82(d)(1) 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:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of two client records on November 4, 2021, the facility failed to provide individual counseling, at least twice weekly. Both clients were receiving individual counseling once a week only.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide individual counseling, at least twice weekly. Although both clients were receiving individual counseling multiple times per week, counselors were only writing one note per week including all the individual and group counseling provided for the particular week. Also, counselors were having clients sign individual sign-in sheets for individual sessions labeled encounter for.
To correct this deficiency, counselors will begin to put separate individual notes for clients showing the participation of the client in individual counseling starting 11/17/2021.
To prevent the reoccurrence of this deficiency, the Executive Director and Quality Assurance coordinator will review client files on a weekly basis to ensure the client is being seen at least twice per week and the sessions are being documented.
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