INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2013 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:
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Plan of Correction
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705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on the physical plant inspection, the facility failed to ventilate toilet and wash rooms by exhaust fan or window in one of two facility bathrooms.
The findings include:
The physical plant inspection was conducted on November 19, 2013 at approximately 10:45 AM. The facility failed to ventilate the client's toilet/wash room as the ventilation unit in the client's toilet/wash room was not working and there were no windows.
The clinical supervisor confirmed that the exhaust fans/ventilation unit was not working at the time of inspection.
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Plan of Correction
Gateway's Director of Environmental Services contacted Housing Authority regarding exhaust fan in clients wash room. Housing maintenance department came to facility on 11/20/13 and diagnosed the problem. Housing informed Director and Moffett house staff that parts to fixed fan will be order. The Director of environmental service will oversee any issues with physical plant at moffett house and contacted housing authority or Gateway's maintenance department. Moffett house staff will monitor physical plant and make report of any issues to clinical manager. |
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 notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of four client records.
The findings include:
Four terminated client records were reviewed on November 5, 2013. All four terminated clients were required to be notified, in writing, of the decision to involuntarily terminate their treatment at the project. Client # 5 did not receive notification, in writing, of the decision to involuntarily terminate his treatment at the project.
Client #5 was admitted to treatment on December 6, 2012 and terminated from treatment on April 1, 2013. There was no documentation that client #5 was notified, in writing, of the decision to involuntarily terminate his treatment at the project.
The findings were discussed with both the facility director and clinical supervisor and were not disputed.
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Plan of Correction
The clinical manager will review termination of treatment process with counselors in supervision. When a client is terminated from treatment the clinical manager will review client's record ensuring that termination of treatment letter was either given to client or sent to client's last known address. |