INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Gate House for Men 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 the facility's Staffing Requirements Facility Summary Report (SRFSR), the project failed to ensure that staff persons and/or volunteers received a minimum of at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum, for one of eight support staff listed.
The findings include:
The facility's SRFSR form was completed by the facility on January 2, 2014 and was reviewed on January 3, 2014. The SRFSR listed one support staff person, employee # 8, as not having completed the mandatory TB/STD training within the regulatory time frame.
Employee # 8 was hired on November 8, 2011. Employee # 8 was required to obtain at least 4 hours of TB/STD training by November 8, 2013. The project failed to ensure that employee # 8 completed at least 4 hours of TB/STD training as of January 3, 2014.
The findings were confirmed by the project director.
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Plan of Correction
Employee #8, hired on November 8, 2011, has been scheduled for the TB/STD training on February 25, 2014. This standard will be corrected and met by February 28, 2014. To ensure that all employees receive necessary trainings in the required time frames, Clinical Supervisors will review Training Plans with counselors and counselor assistants during individual supervision, and with support staff members during group supervision. Clinical Supervisors will terminate employment of staff members who have not completed required trainings. As of February 28, 2014 the facility will be in compliance with all training regulations and requirements. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations in one of four client records.
The findings include:
Four client records requiring documentation of a physical examination were reviewed on January 7, 2014. The facility failed to document a physical examination within 7 days of admission in client record # 4.
Client # 4 was admitted on October 14, 2013 and a physical examination was due to be completed by October 21, 2013. The facility failed to complete a physical examination for client # 4 as of January 7, 2014.
The project director confirmed the findings.
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Plan of Correction
After review of Client #4's chart, admitted on October 14, 2013, a completed History & Physical examination was located in the record. The History & Physical was completed on August 27, 2013 by referring provider, and transmitted to The Gate House for Men on September 11, 2013. Executive Director contacted Drug & Alcohol Licensing Specialist to inform Specialist of this, and was directed to send the History & Physical to Specialist. The H&P was transmitted on January 16, 2014 and the client chart is currently in compliance with the standard.
To assure that History and Physicals are easily accessible in all active client files, the History and Physicals will be found as the first document under the "Medical" label. Inactive files will be audited and remain in the organized order found in the active files. Clients will not be accepted for admission without a completed History and Physical.
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