D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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THE RETREAT AT WHITE BIRCH LLC
80 TERRACE STREET
CARBONDALE, PA 18407

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Survey conducted on 03/25/2025

INITIAL COMMENTS
This report is a result of an on-site provisional license follow-up inspection conducted on March 25, 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 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:	Plan of Correction
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.
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 for a counselor assistant with a high school diploma.Employee #1 was hired as a counselor assistant on November 24, 2024 and was still employed at the time of the inspection. This finding was reviewed with the facility staff during the licensing process.	Plan of Correction The Retreat at White Birch 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 for a counselor assistant with a high school diploma. Employee #1 was hired as a counselor assistant on November 24, 2024, and is set to graduate with a bachelor's degree in May of 2025. Although she was being directly supervised by our clinical supervisor for the first 3 months, the clinical supervisor failed to use the proper language in the supervision notes. Secondly, the Clinical Supervisor failed to use the proper language in the Counselor Assistant supervision notes although the CA was and is being trained under close supervision. To correct this facility, a Clinical Supervisor Staff meeting will be held to discuss the proper way of writing Counselor Assistant supervision notes using the proper language for the type of supervision being used. Also, we will review DDAP regulations regarding the types of supervision that are to be provided when a CA has no degree or when a CA has a degree that meets the requirements for training as a counselor assistant. To prevent the recurrence of this deficiency, regulations concerning the supervision of counselor assistants will be discussed at the monthly Clinical Supervision between the Executive Director and the Clinical Supervisors. All supervision notes will be reviewed at the monthly Clinical Supervision meetings to ensure compliance with DDAP regulations.