D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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THE GATE HOUSE FOR MEN
649 EAST MAIN STREET
LITITZ, PA 17543

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Survey conducted on 02/10/2022

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on February 10, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The GateHouse 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:	Plan of Correction
705.6 (3) LICENSURE Bathrooms. 705.6. Bathrooms. The residential facility shall: (3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
Observations Based on a physical plant inspection, the facility failed to ensure hot water temperature not exceed 120 degrees Fahrenheit. The water temperature in the first floor ADA bathroom was 150 degrees and the water in the third-floor bathroom was 130 degrees. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 705.6 (3) the following will be implemented: On 3/10/2022 the Maintenance staff will adjust the hot water temperature and ensure that it does not exceed 120 degrees. The Residential Program Supervisor will monitor the progress of this action step by checking the hot water temperature on the monthly basis during a facility inspection.
705.6 (4) LICENSURE Bathrooms. 705.6. Bathrooms. The residential facility shall: (4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
Observations Based on a physical plant inspection, the facility failed to provide privacy in showers and bathtubs by partitions, doors, or curtains. A second-floor shower did not have a curtain or door providing privacy. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 705.6 (4) the following will be implemented: On 3/10/2022 the Residential Program Supervisor will purchase a shower curtain and install it in the second floor bathroom to ensure privacy. In addition, the Residential Program Supervisor will ensure that all showers have a shower curtain. The Clinical Director will monitor this action step during the monthly facility inspections.
705.6 (7) LICENSURE Bathrooms. 705.6. Bathrooms. The residential facility shall: (7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
Observations Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times. A bathroom on the second floor had dirt stains from condensation and the vent was clogged with dust and dirt allowing poor ventilation. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 705.6 (7) the following will be implemented: Beginning on 3/10/2022, the Residential Program Supervisor will ensure that each bathroom is functional, clean, and maintained in a sanitary manner. In addition, the Residential Program Supervisor will ensure that all the vents are cleaned to allow sufficient ventilation. The Clinical Director will ensure that this action step is maintained by completing a monthly facility inspection.
705.9 (3) LICENSURE General safety and emergency procedures. 705.9. General safety and emergency procedures. The residential facility shall: (3) Limit smoking to designated smoking areas.
Observations Based on a physical plant inspection, the facility failed to limit smoking to designated smoking areas. There were cigarette butts in the gutters outside the third-floor bedroom emergency door which is not a designated smoking area. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 705.9 (3) the following will be implemented: Beginning on 3/10/2022, the Residential Program Supervisor will complete a daily inspection of the facility to ensure that all clients are smoking only in designated areas. The Residential Program Supervisor will ensure that he includes the inspection of all emergency exit areas when conducting his daily inspection of the facility. The Clinical Director will monitor the progress of this action plan during a monthly inspection of the facility.
709.28 (c) (2) 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: (2) Specific information disclosed.
Observations Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to limit the specific information disclosed to 255.5 (b) for a funding source and to include specific information to be released to a primary care in client record # 4. Client # 4 was admitted on January 18, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated January 28, 2022 to a dental company allowed the biopsychosocial and follow-up to be released to an agency with the purpose of funding/case management. Also, an informed and voluntary consent from the client for the disclosure of information dated January 21, 2022 to a primary care agency did not provide the specific information to be released. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 709.28 (C) (2), the following will be implemented: Beginning on 03/10/2022, the Clinical Director will train the clinical staff, case manager, and program assistant on the 5 points of confidentiality listed under 255.5 (b) (1-5). This training will include information that is and is not permitted to be disclose under the specific regulations. The counselors, case manager, and/or program assistant will ensure that each informed and voluntary consent form includes the specific information to be disclosed. Counselors and/or program coordinator will ensure that the information released is restricted to 255.5 b (1-5) regulations. The Clinical Supervisor will monitor the progress of this action plan while completing monthly chart reviews.
709.28 (c) (3) 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: (3) Purpose of disclosure.
Observations Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the purpose of the disclosure. Client # 4 was admitted on January 18, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated January 21, 2022 to a primary care agency did not provide the purpose of the disclosure. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 709.28 (C) (3) the following will be implemented: Beginning on 3/10/2022 the Clinical Director will train the clinicians, case manager, and program assistant on the completion of confidentiality forms to include the purpose of the disclosure. The clinicians, case manager, and program assistant will ensure that the purpose of the disclosure is identified on each consent form. The Clinical Supervisor will monitor the progress of this action step during the monthly chart reviews.
709.28 (d) LICENSURE Confidentiality § 709.28. Confidentiality. (d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
Observations Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a copy of the consent offered to the client and maintained in the client record. Client # 1 was admitted on November 15, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 15, 2021 to a funding source did not document if a copy of the consent was offered to the client. Client # 6 was admitted on August 4, 2021 and was discharged on October 11, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 4, 2021 to an emergency contact did not document if a copy of the consent was offered to the client. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 709.28 (d) the following will be implemented: Beginning on 3/10/2022 the Clinical Director will train the clinicians, case manager, and program assistant on the completion of confidentiality forms to include the copy of the consent formed being offered to each client. The clinicians, case manager, and program assistant will ensure that they ask the client if they would like a copy of each consent form that is completed on their behalf, in addition the clients acceptance or refusal of the copy will be documented on the consent form. The Clinical Supervisor will monitor the progress of this action step during the monthly chart reviews.
709.32 (c) (1) (i) - (ii) LICENSURE Medication control § 709.32. Medication control. (c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to: (1) Administration of medication, including the documentation of the administration of medication: (i) By individuals permitted to administer by Pennsylvania law. (ii) When self administered by the client.
Observations Based on six of six applicable client records reviewed, the facility failed to provide documentation of the administration of medication according to the facility policy and procedure manual. The policy and procedure manual indicates that both the staff and client will document on the medicated administration record whether or not the medication was taken. Client # 2 was admitted on December 6, 2021 and was still active at the time of the inspection. A medication prescribed to be taken one tablet daily at 7am was not documented on the medication administration record to have been taken one tablet daily at 7am on the date of January 30, 2022. Client # 3 was admitted on December 9, 2021 and was still active at the time of the inspection. Two medications prescribed to be taken one tablet daily at 7am was not documented on the medication administration record to have been taken one tablet daily at 7am on the dates of December 14, 18, 19-31, 2021, January 1, 2, 4, 5, 8, 9, 11-22, 24-28, 30- February 9, 2022 and December 14, 18-20, 22, 24-28, 2021, January 1, 2, 16, 2022. A medication prescribed to be taken one tablet two times daily at 7am and 9pm was not documented on the medication administration record to have been taken one tablet two times daily at 7am and 9pm on the dates of December 10, 13, 14, 16, 18, 20, 21, 22, 24-28, 31, 2021, January 1-3, 9, 12, 15, 16, 28, 31, February 1, 5, 6, 8, 2022. A medication prescribed to be taken one tablet at bedtime was not documented on the medication administration record to have been taken one tablet at bedtime on the dates of December 14, 18, 19, 21, 2021, January 5, 7-9, 11- February 9, 2022. A medication prescribed to be taken one tablet at 9pm was not documented on the medication administration record to have been taken one tablet at 9pm on the dates of December 27, 28, 31, 2021, January 6, 12, 15, 28, 31, February 1, 5, 6, 8, 2022. A medication prescribed to be taken one tablet two times daily at 7am and 4pm was not documented on the medication administration record to have been taken one tablet two times daily at 7am and 4pm on the dates of December 10, 12, 14-31, 2021, January 1-31, February 1-9, 2022. Client # 4 was admitted on January 18, 2022 and was still active at the time of the inspection. A medication prescribed to be taken one tablet two times daily at 7am and 4pm was not documented on the medication administration record to have been taken one tablet two times daily at 7am and 4pm on the dates of January 30, and February 2, 8, 2022. A medication prescribed to be taken one tablet three times daily at 7am and 4pm and 9pm was not documented on the medication administration record to have been taken one tablet three times daily at 7am and 4pm and 9pm on the dates of January 29, 30, February 7, 9, 2022. A medication prescribed to be taken one tablet two times daily at 7am and 9pm was not documented on the medication administration record to have been taken one tablet two times daily at 7am and 9pm on the dates of January 29, 30, February 7, 2022. A medication prescribed to be taken one tablet at 9pm was not documented on the medication administration record to have been taken one tablet at 9pm on the dates of January 29, 30, February 7, 2022. Client # 5 was admitted on July 14, 2021 and was discharged on September 22, 2021. Two medications prescribed to be taken one tablet daily at 7am was not documented on the medication administration record to have been taken one tablet daily at 7am on the dates of July 15, 17, 18, August 8, 15, 22, 29, September 11, 12, 18 and July 17, 18, August 8, 15, 29, September 11, 12, 2021. A medication prescribed to be taken one tablet two times daily at 7am and 9pm was not documented on the medication administration record to have been taken one tablet two times daily at 7am and 9pm on the dates of July 17, 18, August 5, 8, 9, 15, 16, 18, 19, 21, 22, 24, 26, 27, 29, September 2, 3, 5, 7, 10-17, 20, 21, 2021. Client # 6 was admitted on August 4, 2021 and was discharged on October 11, 2021. Two medications prescribed to be taken one tablet daily at 9pm was not documented on the medication administration record to have been taken one tablet daily at 9pm on the dates of August 7, 8, 10, 13, 15, 29, September 3-6, 8, 11-14, 18, October 10 and August 7-15, 29, September 3-6, 8, 11-14, 16, 18, October 10, 2021. Two medications prescribed to be taken one capsule daily at 7am was not documented on the medication administration record to have been taken one capsule daily at 7am on the dates of August 7, 8, 12, 14, 15, 21, 22, 28, 29, September 5, 6, 13, 16, 18, 19, 26, 29, October 10 and August 7, 8, 12, 14, 15, 21, 22, 28, 29, September 5, 6, 9, 13, 16, 18, 19, 26, 29, October 10, 2021. A medication prescribed to be taken two capsules daily at 9pm was not documented on the medication administration record to have been taken two capsules daily at 9pm on the dates of August 7, 8, 10, 13, 15, 29, September 3-6, 8, 11-14, 16, 18, October 10, 2021. A medication prescribed to be taken one tablet daily at 7am was not documented on the medication administration record to have been taken one tablet daily at 7am on the dates of August 7, 8, 12, 14, 15, 21, 22, 28, 29, September 5, 6, 8, October 10, 2021. Client # 7 was admitted on August 31, 2021 and was discharged on October 26, 2021. Two medications prescribed to be taken three tablets daily at 7am, 4pm, 9pm was not documented on the medication administration record to have been taken three tablets daily at 7amy, 4pm, 9pm on the dates of September 2-October 26, 2021 and September 2-October 26, 2021. A medication prescribed to be taken one capsule daily at 7am was not documented on the medication administration record to have been taken one capsule daily at 7am on September 2-October 26, 2021. A medication prescribed to be taken one tablet daily at 9pm was not documented on the medication administration record to have been taken one tablet daily at 9pm on September 1-October 26, 2021. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 709.32 (c), the following will be implemented: Beginning on 3/10/2022, the Clinical Director will ensure that all staff are trained on documenting whether or not the client has taken their medication on the Medication Administration Records. The staff assigned to complete the observation of the administration of medications, will indicate the reason why the client did not take their medication on the Medication Administration Records, and have the client sign off. The Director of Programs will monitor the progress of this action plan during monthly supervisions.
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.
Observations Based on one of one applicable client records reviewed, the facility failed to provide documentation of written notification to the client the decision to involuntarily terminate the client's treatment and the reason for the termination. Client # 6 was admitted on August 4, 2021 and administratively discharged on October 11, 2021. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 709.33 (a), the following will be implemented: Beginning on 3/10/2022, the clinicians will ensure that an Involuntary Treatment Termination form is completed each time a client is administratively discharged. The Involuntary Treatment Termination form will include the reason for the termination of treatment, and a copy of the form will be mailed to the client following the termination of treatment. The Clinical Supervisor will monitor the progress of this plan during the completion of monthly chart reviews.
709.53(a)(11) LICENSURE Follow-up information 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: (11) Follow-up information.
Observations Based on two of three applicable discharged client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur seven days, thirty days, and ninety days after discharge. Client # 6 was admitted on August 4, 2021 and was discharged on October 11, 2021. A follow-up was due to occur November 2021 and January 2022 however, there was no follow-up information documented in the client record. Client # 7 was admitted on August 31, 2021 and was discharged on October 26, 2021. A follow-up was due to occur November 2021 and January 2022 however, there was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 709.53 (a) (11), the following will be implemented: Beginning on 3/10/2022, the Program Assistant will ensure that all follow-up contacts are completed on all clients post discharge during the following intervals, 7 days, 30 days, 60 days and 90 days. The Clinical Director will monitor this action plan monthly when reviewing the quality inspection reports.