INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29-30, 2025, 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to have the Clinical Supervisor who has not functioned for 2 years as supervisors in the provision of clinical services complete a core curriculum in clinical supervision in one of one applicable record reviewed. Employee #2 was promoted from counselor to clinical supervisor on December 9, 2025 and was current in that position at the time of licensing inspection. Employee #2 did not have the required two years of experience as a supervisor and had not completed the core curriculum in clinical supervision training at time of licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of personnel records, the facility failed to ensure that a Clinical Supervisor who had not functioned for two years as a supervisor in the provision of clinical services completed a core curriculum in clinical supervision, as required. This deficiency was identified in one of one applicable personnel records reviewed.
Employee #2 was promoted from Counselor to Clinical Supervisor on December 9, 2025, and was serving in that position at the time of the licensing inspection. Employee #2 did not have the required two years of supervisory experience and had not completed the required core curriculum in clinical supervision at the time of inspection.
Correction:
The Clinical Supervisor enrolled in a clinical supervision training comparable to DDAP's required core curriculum on November 5, 2025. The Clinical Supervisor successfully completed the full course and associated testing on November 10, 2025, and received a certificate of completion. The certificate has been placed in the employee's personnel file to document compliance.
Prevention of Recurrence:
The facility will ensure that any future employee promoted into a Clinical Supervisor position who does not meet the two-year supervisory experience requirement will complete an approved core curriculum in clinical supervision prior to assuming supervisory duties or within the timeframe permitted by regulation.
Person Responsible:
The Executive Director will be responsible for verifying training requirements prior to promotion and for ensuring all certificates are properly maintained in personnel files. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure hot water temperature did not exceed 120 sink in the bathroom shared by clients and staff, read at a temperature of 136.9 when tested during licensing inspection.These findings were reviewed with facility staff during licensing process.
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Plan of Correction
During the licensing inspection, it was determined that the facility failed to ensure hot water temperatures did not exceed the regulatory maximum of 120°F. The hot water at the bathroom sink shared by clients and staff was measured at 136.9°F at the time of inspection.
A mixing valve was installed on the hot water supply lines beneath the bathroom sink to regulate and ensure that the water temperature does not exceed 120°F. This corrective action was completed on 11/07/2025
To prevent recurrence of this deficiency, the Clinical Supervisor will conduct weekly hot water temperature checks in the outpatient facility.
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