INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 2015 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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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on an interview with the project director and a review of personnel records, the facility failed to employ a facility director.
The findings include:
An interview with the project director and review of personnel records was completed on 2/5/2015. Employee # 2, the facility director, resigned on 1/16/2015. The facility did not have a facility director at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since 2/19/15, the facility has been in compliance with the protocol for this standard. On that date, notice was placed in the personnel file of the Project Director that he is also the acting Facility Director in the interlude between the former Project Director's departure (on 1/16/15) and the arrival of her replacement (on 3/9/15). Notice was sent out internally about this on the same day.
The Project Director will assure that in the future, the role of Facility Director is always filled, that appropriate notice of who is filling the role is in that person's personnel file, and that all employees at the facility are aware of who the Facility Director is. Whenever there is a transition to the one we are going through, where the Facility Director resigns, the Project Director will determine who is the Acting Facility Director and assure that the acting Facility Director has appropriate notice of that role in their personnel file and that all employees are aware of who the acting Facility Director is. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records and an interview with the Clinical Supervisor, the facility failed to obtain documentation that a counselor assistant is working toward meeting the qualifications for the position of counselor in two of two personnel records reviewed.
The findings include:
Two counselor assistant personnel records requiring documentation that the counselor assistant is working toward counselor status were reviewed on 2/4/2015. Per regulation, a counselor assistant shall document to the facility director that he/she is working toward counselor status. This information shall be documented upon completion of each calendar year. The facility failed to provide documentation that the counselor assistant is working toward meeting the qualifications for the position of counselor in staff records # 4 and 10.
Employee # 4 was hired on 3/25/2013 and promoted to counselor assistant on 11/10/2014. Employee # 4 did not provide documentation by December 31, 2014 that he is working toward counselor status.
Employee # 10 was hired on 5/8/2011 and promoted to counselor assistant on 6/3/2013. Employee # 10 did not provide documentation by December 31, 2014 that he is working toward counselor status.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of March 9, 2015, we will be in compliance with the requirements of 704.10. By that date, staff members #4 and #10 will have provided a document, approved by the Facility Director, showing evidence that they are working toward counselor status and meet the requirements of DDAP regulations section 704.10. This document will include educational and other goals related to achieving Counselor status accomplished during calendar year 2014 and remaining required goals (education, testing) that must be accomplished to achieve Counselor status and estimated timing of achieving those goals. The Facility Director will confirm these staff members meet the requirements of 704.10 and will include the documents described immediately above in their personnel records.
Going forward, the facility will document that each Counselor Assistant is working toward Counselor status at the end of each calendar year. Every Counselor Assistant will be required every December to document their progress toward Counselor status. The Facility Director will train Counselor Assistants by explaining the documentation required and eliciting letters from them. The Facility Director will ensure that the Counselor Assistants are making progress, and ensure that the Administrative Coordinator keeps copies in each Counselor Assistant's personnel file.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training upon employment in three of five personnel records reviewed.
The findings include:
Five personnel records requiring documentation of fire extinguisher training were reviewed on 2/4/2014. The facility failed to document the completion of fire extinguisher training upon employment in personnel record # 3, 5 and 7.
Employee # 3 received contracted employment with the facility on 12/1/2014 as a counselor. Employee # 3 did not complete the fire extinguisher training.
Employee # 5 was hired on 3/4/2014 as a program coordinator. Employee # 5 completed the fire extinguisher training on 3/13/2014.
Employee # 7 was hired on 10/21/2014 as a recovery specialist. Employee # 7 completed the fire extinguisher training on 12/4/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All full-time staff members at the facility have received fire safety and fire extinguisher use training as of 2/10/15. Contract employee #3 completed her fire safety training on 2/25/15.
In future, the facility will document training for staff in fire safety and the use of fire extinguishers upon hire. New staff members will be trained by the Administrative Coordinator using appropriate training materials during the new staff member's orientation, which occurs on their first shift at the facility or before. The Administrative Coordinator will instruct the new staff member on how to complete a training evaluation related to the fire safety training, which will then be included in the employee file. The Administrative Coordinator will also include this requirement on the staff orientation checklist, and ensure that it is being completed immediately upon hire. In future, contract employees will follow the same standard as new staff members. The facility will be in compliance with this standard with all new staff members and contracted employees hired on or after March 2, 2015.
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. 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, the facility failed to document a preliminary treatment plan in ten of ten client records reviewed.
The findings include:
Ten client records requiring documentation a preliminary treatment plan were reviewed during the renewal inspection on 2/4/2015. A preliminary treatment plan was not documented in client records # 1 - 10.
Client # 1 was admitted to treatment on 12/1/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 2 was admitted to treatment on 11/17/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 3 was admitted to treatment on 11/12/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 4 was admitted to treatment on 7/24/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 5 was admitted to treatment on 9/29/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 6 was admitted to treatment on 4/14/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 7 was admitted to treatment on 10/1/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 8 was admitted to treatment on 10/14/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 9 was admitted to treatment on 8/27/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 10 was admitted to treatment on 10/29/2014. A preliminary treatment plan was not completed upon admission for the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/25/15, the Lead Counselor has checked and confirmed that all current clients have a comprehensive treatment plan.
Going forward, the facility will document a preliminary treatment plan for each client on their date of admission. The Lead Counselor will develop and train all staff on the preliminary treatment plan, which will include basic functions of the facility and orientation treatment work. It will be included in the intake paperwork, and the Program Coordinator will be responsible for administering this treatment plan. The clinical staff will continue to develop a comprehensive treatment plan with clients within current policy time frames.
The Lead Counselor will include a check for the preliminary treatment plan during weekly supervision for a period of 3 months to ensure they are being completed. The facility will be in compliance with this standard beginning with all admissions on or after March 9, 2015.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in four of nine client records reviewed.
The findings include:
Nine client records were reviewed for counseling services during the renewal inspection on 2/4/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 5, 6, 7 and 8.
Client # 5 was admitted to the facility on 9/29/2014 and discharged on 12/19/2014. Client record # 5 contained treatment plans dated 10/2/2014 and 10/29/2014 that identified the counseling services to be provided as group therapy weekly. The record did not contain documentation of any group therapy sessions from 10/12/2014 - 10/25/2014 and 11/2/2014 - 11/22/2014.
Client # 6 was admitted to the facility on 4/14/2014 and discharged on 7/13/2014. Client record # 6 contained a treatment plan dated 6/12/2014 that identified the counseling services to be provided as individual therapy weekly. The record did not contain documentation of any individual therapy sessions from 6/29/2014 - 7/12/2014. Furthermore, client record # 6 contained treatment plans dated 4/15/2014, 5/27/2014 and 6/12/2014 that identified the counseling services to be provided as group therapy weekly. Only one group therapy session on 4/23/2014 was scheduled and completed for the client from admission to discharge.
Client # 7 was admitted to the facility on 10/1/2014 and discharged on 12/21/2014. Client record # 7 contained treatment plans dated 10/2/2014 and 10/29/2014 that identified the counseling services to be provided as group therapy weekly. The only group therapy sessions scheduled and completed for the client in October 2014 and November 2014 were 10/29/2014 and 11/26/2014, respectively.
Client # 8 was admitted to the facility on 10/14/2014 and discharged on 1/7/2015. Client record # 8 contained treatment plans dated 11/13/2014 and 12/13/2014 that identified the counseling services to be provided as individual therapy weekly. The record did not contain documentation of any individual therapy sessions from 11/23/2014 - 11/29/2014 and 12/7/2014 - 12/13/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/20/15, we are in compliance with the protocols required by 709.52 with respect to all current clients.
Clients 5 ? 8 had been discharged as of the date of the inspection so that no additional services can be documented or provided to them. Additionally, the clinicians providing services to clients 5 - 8 have both left employment with the facility.
To prevent a recurrence of this issue, we will use the mandated supervisory process to assure that all service included in any client treatment plan are being provided and documented. Specifically:
- In weekly or monthly supervision with Counselor Assistants and Counselors, the Lead Counselor will check to see that all required services are being provided and documented.
- In monthly or quarterly supervision with the Lead Counselor, the Facility Director will check to see that all required services are being provided and documented for any Lead Counselor clients.
- The Facility Director will assure that all supervision as described here is being done, and that all services are being provided and documented. This will be accomplished in part by reviewing all supervision notes quarterly.
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709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in three of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of a complete client record during the renewal inspection on 2/4/2015. The facility failed to document a complete record in client records # 4, 5 and 6.
Client # 4 was admitted on 7/24/2014 and discharged on 11/7/2014. No record of service was documented for July 2014, August 2014, September 2014 and November 2014 in the client's record. Additionally, a discharge summary was not documented in the client's record.
Client # 5 was admitted on 9/29/2014 and discharged on 12/19/2014. The record of service for the client did not include the group counseling sessions that the client attended on 10/2/2014, 10/9/2014, 10/29/2014, 11/26/2014 and 12/10/2014. Additionally, a discharge summary was not documented in the client's record.
Client # 6 was admitted on 4/14/2014 and discharged on 7/13/2014. No record of service was documented for April 2014, May 2014, June 2014 and July 2014 in the client's record. Additionally, a discharge summary was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/20/15, we are in compliance with the protocols required by 709.53 with respect to all current clients.
By 3/11/2015 we will document both a discharge summary and a record of service for clients 4, 5, and 6.
To prevent a recurrence of this problem in the future, the Facility Director will be responsible to assure that regular mandated chart reviews are done as follows:
- The Lead Counselor will review a sample of open charts monthly to assure that provided services are properly documented.
- The Lead Counselor will review a sample of closed charts quarterly to assure that provided services are properly documented.
- The Facility Director will review a sample of the Lead Counselor's open charts monthly and closed charts quarterly to assure that provided services are properly documented.
Any deficiencies found will be reviewed by the Lead Counselor or Facility Director with the clinician providing services at the next supervision or sooner. If a pattern of deficiencies is identified in this process, this pattern and appropriate remedies will be reviewed with all staff at a weekly staff meeting.
The facility will be in compliance with this standard as of March 11, 2015.
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