INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 14 and March 15, 2012, 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(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's policy and procedures and administrative documentation, the facility failed to document an overall plan for addressing training needs, as required by regulation.The findings include:On March 14, 2012, the facility's policy and procedures were reviewed. Per the agency policy and procedure,"a fiscal year training calendar will be kept by Program Directors indicating all staff training topics, dates, and presenters, etc. This information will be submitted by the end of the fiscal year to the Chief Executive Officer for use in developing an overall annual training assessment report." The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. On March 15, 2012, the project/facility director was requested to provide documentation of the overall training plan. The facility's annual report was presented, however, it did not include an overall training plan for the 2011/2012 overall training plan. The facility failed to document the completion of an overall training plan.The project/facility director was interviewed on March 15, 2012. The project/facility director confirmed that an overall plan for addressing training needs was not completed.
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Plan of Correction
Utilizing the information gathered from the annual assessments of staff training needs and the Annual Evaluation of the Overall Training Program, the Project Director will develop the Overall Training Plan for the upcoming training year. The Overall training plan will include training subjects, potential trainers and dates of trainings. As trainings are scheduled they will be posted on the already existing staff training calendar.
The step taken to assure ongoing compliance, the overall training plan will become part of the annual report which is completed on an annual basis at the end of each training/fiscal year.
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705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on the review of the facility's policy and procedures, the facility failed to document written procedures for staff and residents to follow in case of an emergency that included provisions for the evacuation and transfer of residents impaired by alcohol or other drugs.The findings include: The facility's policy and procedures were reviewed on March 14, 2012. The project/facility director was asked to provide the procedure for the evacuation and transfer of residents that are impaired by alcohol or other drugs. The project/facility director was unable to provide written procedures. The finding was not disputed.
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Plan of Correction
The project director and clinical supervisors will meet to revise the current policy/procedure in accordance with the standard, which will address the evacuation of residents that are impaired by the use of Alcohol or other drugs. The policy will include staff involvement, emergency versus non-emergency, the resident's safety, level of care determination, the referral process, and transportation. These procedures will be communicated to all staff members in at a training session on all shifts.
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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 log it was determined that the facility failed to conduct a fire drill during sleeping hours within the past six months. The findings were:A review of the fire drill log was conducted on March 15, 2012. The last documented fire drill during sleeping hours occurred in July 21, 2011 at 6:15 a.m. A conversation with the clinical supervisor at 11:10 a.m. on March 15, 2012 confirmed that no fire drill was conducted within the last six months during sleeping hours .
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Plan of Correction
The Clinical Supervisor will develop a schedule for monthly fire drills that includes all required testing times such as, sleeping hours, days, and evening shifts. The house manager will be responsible for implementing the fire drill schedule each month. To ensure compliance, the Clinical Supervisor will monitor the schedule on a quarterly basis. |
709.24(a)(2) 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:
(2) Treatment models utilized by the project.
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Observations
Based on the review of the facility's policy and procedures, the facility failed to document treatment models and definitions in the agency manual.The findings include: The facility's policy and procedures were reviewed on March 14, 2012. It was noted during the inspection that the treatment models utilized were not documented or defined in the agency manual. The project/facility director was asked to provide the required documentation. The materials presented were treatment methods and not defined treatment models. The finding was confirmed by the project/facility director and clinical supervisor on March 14, 2012.
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Plan of Correction
The Clinical Supervisors have documented evidence based treatment models that are utilized in the treatment process. Prior to being placed in the manual, the project director has reviewed and approved. The clinical supervisors will supervise the clinical staff in the utilization of evidence based treatment models. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on the review of client medication records, the facility failed to document the refusal or non-administration of medications in four of four medication records reviewed.Findings:Seven client records were reviewed on March 14 and 15, 2012. The documentation of administration of medications were reviewed and required in four medication records The facility failed to document the refusal or non-administration of medications in client records # 2, 3, 6, and 7. The facility failed to document the refusal or non-administration of medications in client record # 2. The client was prescribed "Furosemide (1) 40 mg tab a day." The facility failed to document the reason for the missed doses on November 11 and 26, 2011, December 17 and 19, 2011, January 13, 19, 20, 22, 26, 27, and 31, 2012, and February 3 and 5, 2012.The facility failed to document the refusal or non-administration of medications in client record # 3. The client was prescribed Stratera (1) 60 mg tab in the a.m. The facility failed to document the reasons for the missed doses on October 21, 2011 and January 8, 2012. The client was prescribed "Docusate Sodium (1) 100 mg tab in the a.m." The facility failed to document the reasons for the missed dose on January 7, 2012. The client was prescribed Prilosec (1) 20 mg tab a day. The facility failed to document the reason for the missed dose on January 7, 2012. The facility failed to document the refusal or non-administration of medications in client record # 6. The client was prescribed "Buspar (1) 15 mg tab twice a day." The facility failed to document the reason for the missed doses on February 11, 2012. The client did not receive the dose in the morning and evening on February 11,2 012. The client was prescribed "Celexa (1) 40 mg tab in the a.m." The facility failed to document the reasons for the missed dosing on February 11, 2012. The facility failed to document the refusal or non-administration of medications in client record # 7. The client was prescribed "(1) 15 mg tab of Remeron at bedtime." The facility failed to document the reason for the missed dose on January 5, 2012. The findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
The project director and clinical supervisors will meet to revise all medication policy and procedures to address all areas of 709.32 Medication Control. The Clinical Supervisors will meet with the consulting psychiatrist to develop appropriate policy and procedure that addresses client refusal and missed doses of medication to determine appropriate response to missed doses. Clinical Supervisors will implement a Medication Incident Log to document refusals and missed doses. This log will be reviewed daily upon shift change. Clinical Supervisors will meet with staff to educate them on the use of the new form. Clinical Supervisor will ensure compliance during review of medication log during the weekly staff meeting. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
Based on the review of the facility's policy and procedure, the facility failed to document an inventory of client medications.The findings include:The facility's policy and procedures were reviewed on March 14, 2012. Based on the facility's policy, "The inventory of stored medication is done at the time of the quarterly inspection by the Clinical Supervisor and designated staff." Staff were requested to provide the quarterly inventory of stored medication. The staff were unable to provide the required documentation and stated that they were not conducting inventories of client medications. The clinical supervisor confirmed this finding.
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Plan of Correction
The project director and clinical supervisors will meet to revise all medication policy and procedures to address all areas of 709.32 Medication Control to include the policy and procedure of inventory. The clinical supervisors will meet with all staff to educate them on the procedures which will include the ongoing inspection and inventory of all incoming medication. Clinical Supervisors will ensure compliance during their quarterly inspection of the medication storage area. |
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.
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Observations
Based on a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in three of three records reviewed. The findings include:Seven client records were reviewed on March 14 and 15, 2012. Three clients were involuntarily discharged and required the facility to notify the client, in writing, of the decision to involuntarily terminate the clients treatment at the project. The facility did not provide clients #1 and 3 with a notification in writing. There was documentation of a notification of termination letter in client record # 5, however, it ws unable to be determined if the client received a copy of the termination letter. Client # 1 was admitted to the program on January 19, 2012 and was involuntarily terminated from the program on January 31, 2012. The facility did not notify the client in writing of the reason was for his termination from the program.Client # 3 was admitted to the program on October 17, 2011 and was involuntarily terminated from the program on January 9, 2012. The facility did not notify the client in writing of the reason was for his termination from the program.Client # 5 was admitted to the program on July 21, 2011 and was involuntarily discharged on October 3, 2011. The client record had a termination letter in it; however, there was no indication that the client received a copy. There was no place for the client to sign off on the notification. The finding was confirmed by the clinical supervisor on March 14, 2012 at 1:30 p.m.
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Plan of Correction
The Clinical Supervisors have met and updated the Notification of Involuntary Termination Notice to include signature lines for the client and witness. The notice also includes documentation as to whether the client has received or declined a copy of the notice. The project director has approved the revision. The clinical supervisors will educate the staff on the use of this notice during the weekly staff meeting, and ensure compliance during monthly closed chart reviews. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to inform the client, that they have the opportunity to request reconsideration of the decision to terminate treatment in three of three client records. The findings include:Seven client records were reviewed on March 14 and 15, 2012. Three clients were involuntarily discharged and required the facility to allow the client to have the opportunity to request reconsideration of the decision to terminate treatment in client records # 1, 3, and 5. Client # 1 was admitted to the program on January 19, 2012 and was involuntarily terminated from the program on January 31, 2012. There was no documentation in the patient record that indicated that the patient was provided the opportunity to request reconsideration of the decision to terminate treatment. Client # 3 was admitted to the program on October 17, 2011 and was involuntarily terminated from the program on January 9, 2012. There was no documentation in the patient record that indicated that the patient was provided the opportunity to request reconsideration of the decision to terminate treatment. Client # 5 was admitted to the program on July 21, 2011 and was involuntarily discharged on October 3, 2011. The client record had a termination letter in the record that included the client's right to request reconsideration of the decision to terminate treatment, however, there was no indication that the client received a copy. There was no place for the client to sign off on the notification. The finding was confirmed by the clinical supervisor on March 14, 2012 at 1:30 p.m.
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Plan of Correction
The Clinical Supervisors have met and updated the Notification of Involuntary Termination Notice to include instructions on the right to request reconsideration. The project director has approved the revision. The clinical supervisors will educate the staff on the use of this notice during the weekly staff meeting, and ensure compliance during monthly closed 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.
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Observations
Based on the review of client records, the facility failed to document a follow up attempt in one of two client records.The findings include:Seven client records were reviewed on March 14 -15, 2012. The facility's policy stated that clinical staff must contact each discharged client by phone three months after discharge unless they have been referred to another agency and their arrival at that agency is confirmed. Follow-up to other agencies will be conducted within one week following their discharge date. A follow-up attempt was required in two of the client records. The facility did not document a follow up in client record # 5.Client record #5 was admitted on July 21, 2011 and was discharged on October 3, 2011. Follow-up documentation was due by January 3, 2012. The facility failed to document follow-up in this client record as of the date of the inspection. The clinical supervisor confirmed this finding.
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Plan of Correction
The clinical supervisor will meet with the clinical staff to review the current follow up policy and procedure and the documentation required. The assigned counselor will perform follow up per policy. Clinical Supervisor will ensure compliance through follow up monitoring at weekly staff meeting. |