INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20. 2023 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 client records, the facility failed to obtain a completed informed and voluntary consent which is to include the name of a person, agency or organization to whom disclosure is made in two out of eight records reviewed.
Client #1 was admitted on January 3, 2023 and was still active at the time of the inspection. A release of information form was signed and dated on January 3, 2023 that did not include the name of a person, agency or organization to whom disclosure is made.
Client #3 was admitted on January 27, 2023 and was still active at the time of the inspection. A release of information form signed and dated January 27, 2023 did not include the name of a person, agency or organization to whom disclosure is made.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to obtain a completed informed and voluntary consent, which is to include the name of the person, agency, or organization to whom the disclosure is made.
To correct this deficiency, informed and voluntary consents were filled out including the name of the person, agency or organization to whom the information was being made. The respective clients signed the completed consents and were forwarded to the proper person, agency, or organization.
To prevent a re-occurrence of this deficiency, the clinical supervisor and the Quality Assurance Coordinator will inspect the informed and voluntary consent at the biweekly staff meetings to ensure the names of the person, agency or organizations are present on the forms. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to document proposed type of support service on individual treatment plans in eight out of eight records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to document the proposed type of support service on individual treatment plans in eight out of eight records reviewed.
To correct this deficiency, we added the support services identified by the individual clients to their respective treatment plans.
To prevent the re-occurrence of this deficiency, the Clinical Supervisor and the Quality Assurance Coordinator will inspect active treatment plans to ensure that the outside support services as reported by the clients are included in the respective treatment plans. This will be done at all biweekly staff meetings. |
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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of five applicable records reviewed.
Client #1 was admitted on January 3, 2023 and was still active at the time of the inspection. A treatment plan update was completed on March 13, 2023 and an update was due no later than May 13, 2023; however, it was not completed until May 19, 2023. Additionally, the next update was due not later than July 19, 2023; however, it was not competed until August 11, 2023.
Client #4 was admitted on March 30, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 23, 2023 and the next update was due no later than July 23, 2023; however, it was not completed until September 18, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to document treatment plan updates within the regulatory timeframe in two out of five applicable records reviewed.
To correct this action, the treatment plan updates were performed and completed and documentation of timelines was provided to all of the counselors again so they were made aware of when these updates need to be completed.
To prevent the reoccurrence of this deficiency, the Clinical Supervisor and the Quality Assurance Coordinator will meet with clinical staff bi-weekly to ensure that all treatment plan updates are completed on or before the 60-day requirement. |
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 outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of eight applicable records reviewed.
Client #1 was admitted on January 3, 2023 and was still active at the time of the inspection. The treatment plan dated August 11, 2023 indicated two sessions of group therapy per week and one individual session weekly. There was only one group from August 7, 2023 through September 14, 2023.
Client #4 was admitted on March 30, 2023 and was still active at the time of the inspection. The treatment plan dated May 23, 2023 indicated two sessions of group therapy per week and one individual session weekly. There were no individual sessions documented July 3, 2023-July 14, 2023; the week of July 24, 2023 nor the week of August 21, 2023.
Client #7 was admitted on April 19, 2023 and was discharged on June 21, 2023. The treatment plan dated April 26, 2023 indicated two sessions of group therapy per week and one individual session weekly. The last group session was documented on May 12, 2023.
Client #8 was admitted on June 13, 2023 and was discharged on August 7, 2023. The treatment plan dated June 14, 2023 indicated two sessions of group therapy per week and one individual session weekly. There was only one group from June 16, 2023 through August 3, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to ensure that the clients received counseling services according to their individual treatment plans in four out of eight applicable records reviewed.
To correct this deficiency, the Record of Service for each individual client was updated to reflect when the client did not show up for his or her individual or group counseling session.
To prevent the re-occurrence of this deficiency, a staff meeting was held explaining to the clinical staff the requirement to document on the record of service, when the client is scheduled for treatment. Whether the client shows up or not needs to be documented always. The clinical supervisor and the Quality Assurance Coordinator will inspect client files at biweekly staff meetings to ensure Records of Service match the Level of Care counseling services. |