INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2020 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 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drills from January 2020 to November 2020 the facility failed to conduct at least one fire drill every month as April 2020 and May 2020 were both missing a fire drill.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility failed to conduct at least one fire drill during the months of April 2020 and May 2020 due to the Covid-19 shut down that was in effect.
To correct this deficiency and prevent a re-occurrence of this deficiency, the Executive Director will come to the facility and conduct a fire drill if there is another State shutdown or any other form of emergency that requires our Outpatient facility to shut down in the future |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in five client records.
Client#1 was admitted on January 7, 2020 and was still active at the time of inspection. A comprehensive treatment plan was created on January 9, 2020 and an update was due no later than March 9, 2020. A treatment plan updated was not completed until September 21, 2020.
Client#2 was admitted on April 9, 2020 and was still active at the time of inspection. A treatment plan updated was created on July 28, 2020 and an update was due no later than September 28, 2020. The treatment plan update was not completed until October 12, 2020.
Client#3 was admitted on June 12 and was still active at the time of inspection. A treatment plan updated was created on August 20, 2020 and an update was due no later than October 20, 2020. The treatment plan update was not completed until November 19, 2020.
Client#6 was admitted on April 29, 2020 and was discharged on December 7, 2020. A treatment plan updated was created on July 1, 2020 and an update was due no later than September 1, 2020. There was no update at the time of inspection.
Client#7 was admitted on May 4, 2020 and was discharged on September 30, 2020. A treatment plan updated was created on June 11, 2020 and an update was due no later than August 11, 2020. The updated was not completed until September 3, 2020.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspections conducted on October 9, 2019 and October 15, 2018.
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Plan of Correction
Our facility failed to ensure that treatment and rehabilitation plans were reviewed and updated every 60 days in the client files.
To correct this deficiency, three new counselors were hired. One in August 2020 and two in October 2020. The Executive Director conducted staff meetings discussing the regulations that need to be followed including treatment plan updates every 60 days in both August and October 2020 as new staff members were being hired.
To prevent re-occurrence of this deficiency, the Executive Director will conduct routine biweekly staff meetings to address client files including treatment plan updates being conducted every 60 days. Also the Executive Director and the Quality Assurrance Coordinator will review client files on a weekly basis to ensure all client files have the necessary documents including treatment plan updates every 60 days. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 seven client records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in six client records.
Client#1 was admitted on January 7, 2020 and was still active at the time of inspection. A comprehensive treatment plan and treatment plan update indicated two individual session a week. The chart ' s record of service and progress notes indicated that the client received no session from April 16, 2020 until November 16, 2020 and again from November 25, 2020 until time of the inspection.
Client#2 was admitted on April 9, 2020 and was still active at the time of inspection. A treatment plan updated was created on July 28, 2020, indicated one individual session and two group session as week. The record of service and progress notes indicated that the client received no group session since June 30, 2020.
Client#3 was admitted on June 12, 2020 and was still active at the time of inspection. A treatment plan update was created on August 20, 2020 and indicated one individual session and two group session a week. The record of service and progress notes indicated that the client has not received an individual session since October 6, 2020 and group session since November 17, 2020.
Client#4 was admitted on July 27, 2020 and was still active at the time of inspection. A treatment plan update was created on October 2, 2020 and indicated one individual session and two group sessions a week. The record of service and progress notes indicated that the client has not received any individual sessions or group sessions since September 10, 2020.
Client#5 was admitted on February 13, 2020 and was discharged on September 16, 2020. A treatment plan update was created on April 14, 2020 that indicated one individual session and two group sessions a week. The record of service and progress notes indicated that the client did not receive any group sessions for the months of April, May, July and August 2020.
Client#6 was admitted on April 29, 2020 and was discharged on December 7, 2020. A treatment plan update was created on July 1, 2020 that indicated one individual session and two group sessions a week. The record of service and progress notes indicated that the client ' s last group session was September 11, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in six client records.
To correct this deficiency a staff meeting will be held on Januaruy 6, 2021 to train the counselors on the need to document all correspondence with clients when they are no-showing, canceling, and rescheduling appointments. Even if the clients are assuring the counsleors that they still wish to be active clients but continually no show, we need to document every no show and cancelation and reschedule and the reason why, in the client record.
to prevent re-occurence of this deficiency, the Executive Director and the Quality Assurance Coordinator will review on a weekly manner the client files to make sure the clients' records case notes reflect the missed appointments and the reason why. |