INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 2017, by staff from the Division of Drug and Alcohol 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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704.11(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 facility records and staff interviews conducted during the onsite inspection, the facility failed to ensure that all of the staff had the required training in communicable diseases.
Staff person #2 was hired as a counselor on 08/10/2016, but the facility had no documentation that the staff person received the required 6 hours of HIV/AIDS training or the required 4 hours of TB/STD training.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Staff person #2 was working on his training requirements for the year as a counselor but at the time of the inspection, the facility could not produce the documentation to provide proof of Staff person #2 having taken this training as required. Staff person #2 was terminated from employment on 11/14/2017. After investigation, it was determined that Staff person #2 never scheduled or participated in the 6 hours of HIV/AIDS training or the required 4 hours of TB/STD training. To correct this deficiency the facility will require staff members to provide certificates of the trainings within 5 work days of having taken a required training course.
To prevent reoccurrence of this deficiency, the quality assurance coordinator along with the Executive Director will perform biweekly reviews of the training binders to ensure the that training plans are being followed and documentation of the required trainings are inserted into the binder with dates and certificates entered into the record.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on staff interviews and the direct observation of the licensing specialist conducted during the onsite inspection, the facility failed to ensure privacy during counseling sessions.
The individual counseling session could be heard and understood from the offices adjacent to the counselor offices.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Individual counseling sessions could be heard in the adjacent office. To correct this deficiency, noise machines were purchased and placed into all offices. In the event of an individual session, the counselor will turn on the noise machine to a level that allows for the session to be conducted in private.
To prevent reoccurrence of this deficiency, the Executive Director and the Quality Assurance Coordinator biweekly staff meetings will address the idea that noise machines need to be used consistently in the counseling sessions.
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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 conducted during the onsite inspection, the facility failed to include all of the required documentation on its consent to release information forms in 2 client records reviewed.
Client #1 had a consent to release information form for a doctor dated 11/08/2017, but the purpose of the release is listed only as, "other."
Client #1 had a consent to release information form for counseling services dated 11/22/2017, but the purpose of the release is listed only as, "other."
Client #3 had a consent to release information form for a healthcare provider dated 11/02/2017, but the purpose of the release is listed only as, "other."
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Consent to Release Information forms were being filled out but the specifics of the purpose of these forms were not being documented. Instead, a check mark was being used next to the choice of "other" with no specifics. To correct this deficiency, the Consent to Release Information forms were updated on 12/07 2017 to give a more specific description of the use or purpose of the individual form.
To prevent reoccurrence of this deficiency, biweekly reviews of the client files by the Executive Director and the Quality Assurance Coordinator will ensure that Consent to Release Information forms are specific and descriptive in explaining their purpose while protecting the privacy and confidentiality rights of the client.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records conducted during the onsite inspection, the facility failed to complete preliminary treatment plans in 3 of 6 applicable records.
Client #1 was admitted for treatment on 11/08/2017, and was an active client at the time of the onsite inspection.
Client #2 was admitted for treatment on 10/05/2017, and was an active client at the time of the onsite inspection.
Client #6 was admitted for treatment on 10/31/2017, and was an active client at the time of the onsite inspection.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Preliminary Treatment plans were not completed and entered into the client files for client #s 1, 2 and 6. To correct this deficiency, we developed a standardized preliminary treatment plan that will be used for all clients to focus on until they develop a comprehensive treatment plan with his or her Primary Counselor. These Preliminary Treatment Plans will be implemented during the intake/admission process.
To prevent reoccurrence of this deficiency, biweekly reviews of the client files will be performed by the Executive Director and Quality Assurance Coordinator. Also, biweekly staff meetings will be conducted to be sure all regulations are being followed.
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records conducted during the onsite inspection, the facility failed to document the type and frequency of services for the individualized treatment plans in 2 of 6 applicable records.
Client #3's individualized treatment plan was dated 08/25/2017.
Client # 4's individualized treatment plan was dated 08/11/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Facility did not document in Client #3's and Client #4's treatment plan that he was attending group and individual counseling sessions and the frequency of these sessions. Clients #3 was attending individual counseling sessions twice a week and his treatment plan was updated on 12/15/2017 to document the type and frequency of his treatment and rehabilitation services. Client #4 was attending individual counseling sessions once every two weeks and group counseling sessions two times per week. Client #4's treatment plan was updated on 12/15/2017 to document the type and frequency of the treatment and rehabilitation services. To correct this deficiency, treatment plan templates were updated on 11/1/2017 to include the type of treatment service and the frequency of the services. Since 12/15/2017 all client treatment plans are being inspected and updated when necessary and this process will be completed by 12/22/2017
To prevent reoccurrence of this deficiency, biweekly reviews of the client files will be conducted by the Executive Director and the Quality Assurance Coordinator. Biweekly staff meetings will be held by the Executive Director to train clinical staff and implement the updates going forward.
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