INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 16, 2018 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:
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Two personnel records were reviewed for the counselor assistant position on March 15, 2018, for the licensing renewal inspection conducted on March 16, 2018. The facility failed to fully document the provision of direct observation for employee records # 4 and 5. Employee # 4 was hired by the project on 12/7/15 and began employment as a high-school diploma level counselor assistant on 6/13/16. The employee required direct observation and close supervision for the first 12 months of employment in the counselor assistant position. Weekly supervision notes were reviewed for the period of 3/6/17 - 6/16/17. The facility failed to demonstrate that weekly close supervision included 1 hour of direct observation at least once per week. Employee # 5 was hired by the project on 9/22/15 and began employment as a bachelor's level counselor assistant on 11/14/16. The employee required close supervision for at least the first 6 months of employment in the counselor assistant position. Weekly supervision notes were reviewed for the period of 3/6/17 - 5/15/17. The facility failed to demonstrate that weekly close supervision included 1 hour of direct observation at least once per week. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
In an effort to address citation 704.9 (c), the following will be implemented.
In the event that a counselor assistant is employed at the Gate House for Men, the Clinical Director will ensure that documented direct observed supervision is conducted weekly for the first year of employment for high school level counselor assistants, and for the first 6 months of employment for bachelor level counselor assistants.
This correction will be implemented by 4/20/2018. The Program Administrator will oversee the implementation of this plan of correction.
|
704.11(a)(4) LICENSURE Evaluation of Overall 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:
(4) An annual evaluation of the overall training plan.
|
Observations
A licensing renewal inspection was conducted on March 16, 2018. The facility's training year was from June 30th, 2016 through July 1st, 2017. The facility failed to provide documentation of an annual evaluation of the overall training plan for the 2016-2017 training year. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
In an effort to address citation 704.11 the following will be implemented.
The Program Administrator and the Human Resources Director will ensure that an evaluation of the organization wide training plan is completed this year by July 16 2018.
The Program Administrator will ensure that this plan of correction is adhered to annually, beginning with the evaluation for the 2017-2018 training year. |
709.32 (c) 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:
|
Observations
Administrative documentation was reviewed for the facility's licensing renewal inspection, conducted on March 16, 2018. The facility failed to provide medication policies that included the provision of medication assisted treatment via the approved use of non-narcotic Vivitrol injections. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 709.32 the following will be implemented.
The Program Administrator has updated the medication policy for the Gate House, to include the provision of Vivitrol. This policy was updated on 4/13/2018.
The Program Administrator will ensure that the new medication policy is implemented by 5/1/2018. In addition, the Clinical Director at the Gate House for Men will ensure that the updated policy is followed, by monitoring its implementation. |
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
Seven client records were reviewed on March 16, 2018. The facility failed to document the provision of written notification to the client of the facility's decision to involuntarily terminate treatment for client record # 7. Client # 7 was admitted into treatment on 10/17/17 and was involuntarily discharged on 1/1/18. Documentation verifying that the client received written notification of an involuntary termination was not found in the client's record. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
In an effort to address citation 709.33 the following has been implemented.
On 3/20/2018, the Clinical Director informed all the clinicians at the Gate House for Men about the importance of completing a treatment termination notice for each client who is discharged (regardless of their discharge status).
In the event that a client is involuntarily discharged from the Gate House for Men, the Clinical Director will ensure that the client is given a treatment termination letter prior to their discharge. This letter will be filed in the client record, and the Clinical Director will review the chart for accuracy prior to the clients discharge. This procedure will begin 5/8/2018.
The Program Administrator will monitor this plan of correction at the quarterly quality inspection meetings, which will start on June 22, 2018. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Seven client records were reviewed on March 16, 2018. The facility failed to completely document the type and/or frequency of counseling services on the individual treatment and rehabilitation plan for client records # 2, 4, 6, and 7. Client # 2 was admitted into treatment on 12/22/17 and was still active in treatment. The comprehensive treatment plan completed for the client on 12/22/17 did not specify the type and frequency of counseling services. Client # 4 was admitted into treatment on 1/9/18 and was discharged on 1/19/18. The comprehensive treatment plan completed for the client on 1/11/18 did not specify the type and frequency of counseling services. Client # 6 was admitted into treatment on 11/15/17 and was discharged on 2/8/18. The comprehensive treatment plan completed for the client on 11/16/17 did not specify the type and frequency of counseling services. Client # 7 was admitted into treatment on 10/17/17 and was discharged on 1/1/18. The comprehensive treatment plan completed for the client on 10/18/17 did not specify the frequency of counseling services. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
In an effort to address citation 709.52 the following has been implemented.
On 3/20/2018 during the clinical meeting at the Gate House for Men, the Clinical Director informed each counselor of the need to document the type and frequency of services on each treatment plan.
The Clinical Director will ensure that each treatment plan includes the type and frequency of services as he reviews and signs off on each treatment plan. This plan of correction has been implemented since 3/21/2018.
The Program Administrator will oversee the completion of this correction monthly as the quality report is reviewed. |