INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide individual paper towels or a mechanical dryer in each bathroom. The second-floor bathroom's automatic paper towel dispenser was empty and was not functioning at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.6(2),the following will be implemented:
Beginning on 3/13/23, the Residential Program Supervisor will ensure that all paper towel dispensers are in working order during the daily house inspections. In the event that a dispenser is not operational, a maintenance order will be submitted for its repair. As of today, this dispenser has been repaired.
The Clinical Director will monitor the progress of this action step during the monthly audit of the physical plant. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility's policy and procedure manual and client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client record reviewed.
Per the policy and procedure manual, the program will contact the participant's emergency contact the same day when the participant leaves treatment against facility advice.
Client #4 was admitted on November 22, 2022 and was discharged against facility advice on January 9, 2023. There was no attempted emergency contact notification documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.24(a)(3), the following will be implemented:
Beginning on 3/13/23 all the clinical staff and case manager will be trained and/or reminded of the procedures for contacting a clients emergency contact within 12 hours following a therapeutic discharge, or if and when a client leaves treatment prematurely. Clinicians, and or the case manager is responsible to make contact with the emergency contact, and document the call in the client contact log.
The Clinical Supervisor will monitor the progress of this action step, each time a client is therapeutically discharged, or leaves treatment prematurely. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent form in one of seven records reviewed.
Client #4 was admitted on November 22, 2022 and was discharged on January 9, 2023. The record included a consent to release information form signed by the client on December 20, 2022, that was missing the name, agency or organization to whom the disclosure was to be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28(c), the following will be implemented:
Beginning 3/13/23, all staff completing a release of information will identify and ensure that the person, agency, or organization is documented on the consent form, as the party to disclose information to.
The Clinical Director will monitor the progress of this action step during monthly chart reviews. |
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.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent form in one of seven client records reviewed.
Client #3 was admitted on January 17, 2023 and was active at the time of inspection. A release of information form to an employer was signed and dated by the client on February 15, 2023; however, the form did not include the specific information to be disclosed.
This is a repeat citation from the February 10, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28(c)(2), the following will be implemented:
Beginning on 3/15/23, the Clinical Director will train all staff providing direct services in the completion of releases of information. This training will include the specific information to be disclosed.
The Clinical Supervisor will ensure that the current release of information for client #3 is updated to include the specific information to be disclosed.
The Clinical Director will monitor all releases of information on a monthly basis to ensure accuracy. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on a release of information form in one of seven client records reviewed.
Client #3 was admitted on January 17, 2023 and was active at the time of inspection. A release of information form to an external, community business was included in the record, but the form did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28 (c)(4), the following will be implemented:
Beginning on 3/15/23, the Program Assistant will ensure that all releases of information completed include a dated signature of the client.
The Program Assistant will meet with client #3 to update the current release of information to include the dated signature of the client.
The Clinical Director will monitor the progress of this action step on a monthly basis during supervision. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in two of five applicable client records reviewed.
Client #4 was admitted on November 22, 2022 and was discharged on January 9, 2023. The individual treatment and rehabilitation plan was completed on November 22, 2022 and the first update was due no later than December 22, 2022; however, the update was not completed until December 30, 2022.
Client #7 was admitted on April 19, 2022 and was discharged on July 20, 2022. The individual treatment and rehabilitation plan was completed on April 21, 2022 and the first update was due no later than May 21, 2022; however, the update was not completed until June 1, 2022. Additionally, the next update was due no later than July 1, 2022; however, the update was not completed until July 13, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.52(b), the following will be implemented:
Beginning on 3/15/23, the Clinical Supervisor will ensure that all treatment plan updates are reviewed and updated every 30 days. The Clinical Supervisor will monitor this action step bi-weekly.
The Clinical Director will monitor the progress of this action step during monthly supervision with the Clinical Supervisor. |