INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center Inc., Moffett House, 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 and a plan of correction is due on February 13, 2009.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to inform the client of the facility's reason for involuntarily terminating the client. The findings include:Eight client records were reviewed on January 15, 2009. The project's decision to involuntarily terminate the client's treatment was required in two client records. The project did not document, in writing to the client, a decision to involuntarily terminate the client's treatment at the project in client records # 2 and # 8.
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Plan of Correction
A termination of treatment form is to be completed for each patient who is given an involuntary discharge, along with their aftercare recommendations. The Clinical Manager will make the following efforts to correct any deficiencies in this area in the future:
1. The Clinical Manager will review all involuntary discharges within 48 hours after discharge. If a termination of treatment form was not completed at the time of discharge, the Clinical Manager will complete one and mail it to the patient's last known address.
2. The Clinical Manager will facilitate training for all Moffett House staff regarding the importance of the termination of treatment form and its procedure. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs and staff interviews, the facility failed to conduct a fire drill during sleeping hours every six months. The findings were:Fire drill logs were reviewed on January 16, 2009. Fire drills during sleeping hours are required to be conducted at least every six months. The facility failed to conduct a fire drill during sleeping hours during the last twelve months.
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Plan of Correction
The Clinical Manager is responsible for planning and facilitating all fire drills at the Moffett House. The Clinical Manager will ensure that a fire drill is held during sleeping hours at least once every six months. The Clinical Manager will send all fire drills to the Director who will review them monthly and ensure that this regulation (regarding fire drills during sleeping hours) is being followed. |