INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3, 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 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 four staff records on November 3, 2021, the facility failed to ensure that one staff had the mandatory training in communicable diseases within the required time frame.
Staff #5 was hired as a counselor on October 5, 2020. The staff person was required to have 6 hours of HIV/AIDS training by October 5, 2021, but at the time of the inspection, the staff person had no documentation of training in this area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility failed to ensure that Staff #5 received a 6-hour training by Oct5, 2021. One year from the counselor's hire date. The counselor was under the impression that he had two years to do the training and as a result, he did not secure the training.
To correct this deficiency, Staff # 5 has been enrolled in a 6-hour DDAP HIV/AIDS Training scheduled for 01/19-20/2022. All counselors and counselor assistants will be informed in writing at the time of hire, that all TB/STD/Hep 4 hour and HIV/AIDS 6 hours trainings are required within the first year of employment.
To prevent the re-occurrence of this deficiency, the Executive Director shall remind staff when the new training plan for the year is implemented, the need to have these trainings done within the first year of employment.
The Executive Director held a staff meeting with the counselors on 11/10/2021 to discuss this as part of our yearly training plan.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of four staff records on November 3, 2021, the facility failed to ensure that one staff had the required number of training hours for the past training year.
Staff #3 was hired as a counselor on July 11, 2016. The staff person was required to have 25 hours of training in the past training year, however only had 21 hours documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Facility failed to ensure that Staff #3 had the required number of training hours for the past training year. Staff #3 was required to have 25 hours of training in the past training year. In 2020, it was very difficult for Staff #3 to get the required amount of hours due to the global pandemic. Staff #3 has many health-related issues that put her at risk of complications from COVID-19. Staff #3 did the best she could finding online training but fell short of the requirement.
To correct this deficiency, Staff #3 has located enough online DDAP training to meet the required amount of training hours for this training year.
To prevent the reoccurrence of this deficiency, the Executive Director will meet on a monthly basis with the Counselors to discuss any issues they may be having obtaining training hours and ensuring that we meet our requirements for the training year. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical site inspection on November 3, 2021, the facility failed to ensure to ventilate toilet and wash rooms by exhaust fan or window.
The bathroom in room 236 did not have a window and the exhaust fan did not work.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Our facility had a ceiling fan in the bathroom for room 216 that was not working properly.
To correct this deficiency, a new fan was purchased and the broken exhaust fan was replaced on 11/12/2021.
To prevent the re-occurrence of this deficiency, The Executive Director and the day Shift Community Manager will conduct weekly physical plant inspections which will include checking that all exhaust fans are functioning properly and make repairs accordingly. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
During a physical site inspection on November 3, 2021, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
Two first floor shower rooms had paint peeling from their ceilings.
The bathroom attached to the group counseling room had what appeared to be black mold around the bottom of the wall where the molding had been removed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Our facility had paint peeling from the ceilings in two of the shower rooms and the bathroom attached to the group room had black mold along the floor of the toilet room where the molding had been removed.
To correct this deficiency, we scraped the ceilings in the two shower rooms on 11/08/2021. They had no primer on the ceilings before the ceilings were popcorned. We are in the process of priming the scraped ceilings and will paint the ceilings immediately following the primer.
In the group room toilet room, we bleached and scrubbed the walls to remove the damage to the wall and installed new vinyl molding around the bottom of the wall.
To prevent the re-occurrence of this deficiency, the Executive Director and the day shift community manager will routinely monitor the shower rooms and the toilet rooms on a weekly basis, as well as the client bedrooms for any repairs that may be needed. Then perform the repairs as needed.
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