INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2024 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 LLC 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.
Employee #6 was hired on January 29, 2024 with a GED equivalent and was still employed at the time of the inspection. She had no documentation of direct or close supervision.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to provide documentation of direct or close supervision for a counselor assistant with a GED equivalent.
To correct this deficiency, the counselor assistant will be supervised under direct observation by the clinical supervisor and then under close supervision for the next 9 months by her clinical supervisor.
To prevent reoccurrence of this deficiency, weekly supervision notes on this employee will be recorded by the clinical supervisor. These will be copied by the company controller and a second set of supervision notes will be kept on file in the Administrative Office.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on September 24, 2024, the facility failed to ensure frozen food was at or below 0 degrees F. The facility did not have a mechanism to ensure the temperature of frozen food was at or below 0 degrees F in the chest freezer in the dining room.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The facility failed to ensure frozen food was at or below 0 degrees F in the chest freezer in the dining room.
To correct this deficiency, a new thermometer was put into the freezer in the dining room to check temperature of the freezer.
to prevent the reoccurrance of this deficiency, the community Managers will check the thermometers daily in all refrigeration and freezers in the facility to ensure the units are cooling properly |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered in six out of seven applicable records.
Client #1 was admitted on June 24, 2024 and was still active at the time of the inspection. She was prescribed Perphenazine 8 mg two times a day. There is no documentation for the medication being administered or the reason not administered on August 11, 2024 in the PM.
Client #2 was admitted on June 26, 2024 and was still active at the time of the inspection. She was prescribed Prazosin HCL 1mg 1 cap at bedtime. There is no documentation of the medication being administered or the reason not administered on July 12, 22, 29 and August 2, 3, 5, 6, 10, 13, 14, 15, 16, 19, 21, and 30. She was prescribed Trazadone 100mg 2 tabs at bedtime. There was no documentation of the medication being administered or the reason not administered on July 2, 3, 5, 6, 10, 13, 14, 15, 16, 19, 21, 29 and August 2, 3, 5, 6, 10, 13, 14, 15, 16, 19, 21, and 30. She was prescribed Folic Acid 1mg 1 time a day. There is no documentation of the medication being administered or the reason not administered on
August 24 and 26.
Client #3 was admitted on June 28, 2024 and was still active at the time of the inspection. She was prescribed Hydroxyzine 25mg 2 tabs at bedtime. There is no documentation of the medication being administered or the reason not administered on July 29 and August 23, 2024. She was prescribed Trazodone 100mg 3 tabs at bedtime. There is no documentation of the medication being administered or the reason not administered on July 15 and 29, 2024. She was prescribed Fluticasone Propionate 113mcg/14mc 1 puff 2 times a day. There is no documentation of the medication being administered or the reason not administered on July 29, August 23 and August 26, 2024. She was prescribed Oxcarbazepine 150mg 1 tab at bedtime. There is no documentation of the medication being administered or the reason not administered on August 23, 2024. She was prescribed Levetiracetam 500mg 1 tab at bedtime. There is no documentation of the medication being administered or the reason not administered on August 23, 2024. She was prescribed Sertraline 25mg 2 tabs at bedtime. There is no documentation of the medication being administered or the reason not administered on August 23, 2024.
Client #5 was admitted on February 28, 2024 and was discharged on April 12, 2024. She was prescribed Gabapentin 300 mg 4 times daily. There is no documentation of the medication being administered or the reason not administered on February 6-11 at noon. She was prescribed Suboxone film 2mg 1 film 2 times daily. There is no documentation of the medication being administered or the reason not administered on February 12, 13 and 28, 2024.
Client #6 was admitted on April 26, 2024 and was discharged on July 22, 2024. She was prescribed Risperidone 2mg 2 times daily. There is no documentation of the medication being administered or the reason not administered two times on June 2, 3, 34, 6, 7, 9, and 11, 2024. Also, July 12, PM dose on July 15, and July 16 and 17 no AM dose. She was prescribed Docusate 100mg 2 times daily. There is no documentation of the medication being administered or the reason not administered twice daily on July 11, 12, 13, 14, and 19, 2024. There is no documentation of the medication being administered or the reason not administered on July 17, 2024. She was prescribed Melatonin 5 mg at bedtime. There is no documentation of the medication being administered or the reason not administered on July 7, 8, 11, 14, 19, 2024.
Client #7 was admitted on June 26, 2024 and was discharged on September 4, 2024. She was prescribed Prazosin HCL 1mg at bedtime. There is no documentation of the medication being administered or the reason not administered on August 4, 2024 and September 1, 3, 2024. She was prescribed Risperidone .5mg at bedtime. There is no documentation of the medication being administered or the reason not administered on September 1 and 3, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to document the administration, or the reason a medication was not administered in the applicable record (med sheet).
To correct this deficiency, the med book missed medication form was removed for the med book and instead, the staff administering medication will document directly onto the med sheet whether the client was administered or missed the medication and the reason for the missed med.
To prevent reoccurrence of this deficiency, the counselors and the controller will monitor the med book on a daily basis to ensure the documentation of the administered and missed meds. The clinical supervisor will hold weekly staff meetings to review the medication book for proper documentation of meds
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709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based upon a physical plant inspection, the facility failed to store medication and controlled substances according to their policy. The policy states medication will " be locked in the medicine cabinet, located in a locked medication room. " Additionally, policy states " All medications considered a Controlled Substance would be stored in a locked container separate from all other medications. This locked container will be kept in the locked medication cabinet in the medication storage area " .
Over the counter medication was observed in a client's room.
Controlled substances were stored in an administrator's office in a locked container.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility failed to store medication and controlled substances according to our policy by locking controlled substances in an Administrative Office. Also, a client took vitamins to her room instead of handing them in to staff.
To correct this deficiency, the policy will be updated to state that controlled substances will be locked in a safe in an Administrative Office for safety and security. The over the counter medication was removed from the client's room and put into the med cart to be available to the client as a PRN.
To prevent reoccurrance of this deficiency, the facility staff will be trained and informed of the updated policy on storage of controlled substances. Clinical Suprevisor will hold a training and weekly staff meetings to discuss medication management, documentation of medication and policies for staff to follow concerning controlled substances and over the counter medications. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 30 days following admission.
Client #5 was admitted on February 28, 2024 and was discharged on April 12, 2024. A case consultation was due no later than March 29, 2024; however, it was not completed until April 4, 2024.
Client #6 was admitted on April 26, 2024 and was discharged on July 22, 2024. A case consultation was due no later than May 26, 2024; however, it was not completed until May 31, 2024.
Client #7 was admitted on June 26, 2024 and was discharged on September 4, 2024. A case consultation was due no later than July 26, 2024; however, it was not completed until August 1, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to document case consultations within the guidelines established by the facility's policy and procedures manual. The facility 's policies and procedures manual states the case consultations must be completed every 30 days following admission.
To correct this deficiency, the facility's policy and procedures manual will be updated to state the case consultations must be completed every 30 days following implementation of the client's Master Treatment Plan.
To prevent reoccurrence of this deficiency, the Clinical Supervisor will review files to ensure the updated policy is being followed by all Clinical Staff . Clinical Supervisor will train and discuss expectations of the counselors concerning the updated Policy during weekly clinical staff meetings.
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