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, 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 and a plan of correction is due on March 23, 2010.
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Plan of Correction
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a tour of the physical plant, the facility failed to store all trash in covered containers.
The findings include:
A tour of the physical plant was conducted on February 18, 2010 at approximately 11:00 A.M. The dumpster in the back of the building did not have a lid to cover its contents.
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Plan of Correction
Clinical Supervisor notified Waste Management of the missing lids on 3/4/10. New lids were installed on the dumpster on 3/8/10. A weekly inspection of the dumpster will be conducted by support staff. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a tour of the physical plant, the facility failed to keep all interior exits and stairs lit at all times.
The findings include:
A tour of the physical plant was conducted on February 18, 2010 at approximately 11:00 A.M. The stairway leading from the third floor to the second floor was unlit.
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Plan of Correction
Clinical Supervisor has contacted our electrician. Electrical work will be completed that will allow the lights to be on at all times. (The switch will be removed.) Work is scheduled to be completed on 3/10/10. All hall lights will be lit 24/7. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill record log, the facility failed to document fire drills during sleeping hours at least every six months.
The findings include:
The fire drill record log was reviewed on February 17, 2010. The log was reviewed for 2008, 2009, and 2010 since the last inspection was conducted on January 28, 2009. The last fire drill conducted during sleeping hours for 2008 was on November 24, 2008 at 10:20 PM, the next sleeping hour drill would have been due to be conducted on May 24, 2009 but had not been conducted until August 1, 2009.
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Plan of Correction
Clinical Supervisor has assigned the Night Manager the responsibility of coordinating the fire drills for all shifts. A fire drill during sleeping hours will be conducted at least every 6 months. An overnight drill will be conducted on 3/9/10. Clinical Supervisor will monitor this on a monthly basis. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document fire drills on a monthly basis.
The findings include:
The fire drill record log was reviewed on February 17, 2010. The log was reviewed for 2008, 2009, and 2010 to determine compliance with the sleeping hour fire drills since the last inspection was conducted on January 28, 2009; however, the log was reviewed from January 2009 to December 2009 to determine compliance with the regulation for conducting monthly fire drills during the 2009 year. Fire drills were missing for three of those twelve months. There was no documentation that a fire drill was conducted for the months of January 2009, June 2009, and July 2009.
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Plan of Correction
Clinical Supervisor has assigned the Night Manager the responsibility of coordinating the fire drills for all shifts. Clinical Supervisor will ensure that monthly fire drills will be conducted. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document an evaluative assessment in the psychosocial evaluations in two out of six client records.
The finding includes:
Seven client records were reviewed on February 17, 2010. One of the seven was only reviewed for documentation related to discharge; therefore, the psychosocial evaluation was not reviewed in record #7. Psychosocial evaluations were due to be documented in six client records, specifically client records # 1, 2, 3, 4, 5, and 6.
Client records # 2 and 5, failed to evaluate the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors that might inhibit treatment. The evaluations lacked a clinical assessment and provided minimal detail. Additionally, the psychosocial evaluation in client record #5 contained much of the client ' s statements and opinions rather than the clinicians assessment.
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Plan of Correction
Clinical Supervisor will conduct a training on Psychosocial Assessments and Treatment Plans for all clinical staff to attend. Training will be held on 3/24/10 at The Gate House for Women from 9-11 a.m. To ensure compliance, the clinical supervisor will review all psychosocial evaluations for a period of three months. If at the end of three months the facility is still out of compliance the clinical supervisor will conduct another training session and continue to review all psychosocial evaluations until compliance is achieved. Once compliance has been achieved, the clinical supervisor will review psychosocial evaluations randomly on a quarterly basis.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of the facility's policies and procedures and client records, the facility failed to document case consultations in two of two client records.
The findings include:
Seven client records were reviewed on February 17, 2010. Case consultations were required in two of the seven client records. The facility policy states case consultations are to be documented at least once during the course of treatment. The facility either failed to document a summary in the case consultation notes or did not include a case consultation at all in client records #6 and 7.
Client record # 6 contained documentation of case consultation notes for the case consultation conducted on August 12, 2009 but failed to include a summary.
Client # 7 was discharged on October 25, 2009. The case consultation was due before October 25, 2009. No documentation of a case consultation was able to be provided at the time of the inspection.
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Plan of Correction
Clinical Supervisor will conduct a training on 3/22/10 to address the content and time frames of case consultations. To ensure compliance, the clinical supervisor will review all case consultations for a period of three months. If at the end of three months the facility is still out of compliance the clinical supervisor will conduct additional training and continue to review all Case Consultations until compliance is achieved. Once compliance has been achieved, the clinical supervisor will review case consultations randomly on a quarterly basis. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to completely document aftercare plans in two of two client records.
The findings include:
Seven client records were reviewed on February 17, 2010. Aftercare plans were required in two of the seven client records. The facility failed to document aftercare plans to include support services, the re-entry process and/or contact person. in client records #6 & 7.
Client record # 6 contained documentation of an aftercare plan but failed to include support services, a contact person, and reentry process.
Client record #7 contained documentation of an aftercare plan but did not contain contact information for support services and a reentry process.
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Plan of Correction
Clinical Supervisor had the aftercare form revised to include supportive services, referrals, and contact information and phone number for reentry. The clinical supervisor conducted a training on 3/15/10 to ensure staff will be educated in the use of this new form. Clinical Supervisor will ensure that all clients will receive all after care plans through staff meeting and chart reviews. Compliance will also be assured through chart reviews.
The clinical supervisor will review all aftercare plans for a period of three months. If at the end of three months the facility is still out of compliance the clinical supervisor will conduct another training session and continue to review all aftercare plans until compliance is achieved. Once compliance has been achieved, the clinical supervisor will review aftercare plans randomly on a quarterly basis. |
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.
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Observations
Based on a review of the facility's policy and procedure manual and client records, the facility failed to document follow up information in one of two client records.
The findings include:
Seven client records were reviewed on February 17, 2010. Follow up information was required in two of the seven client records; specifically client records # 6 and 7. The facility policy states follow ups are to be conducted three months after the client leaves the facility.
Client #7, was discharged on October 25, 2009, a follow up attempt was due by January 25, 2010. No Follow up information had been documented as of the date of the inspection.
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Plan of Correction
Clinical Supervisor will review follow up policy with staff. Follow ups will be done within 5 working days if referred to another facility. A 3 month follow up will be coordinated by the primary counselor as per the facility's policy and procedure manual. Clinical Supervisor will conduct chart reviews to ensure compliance. |