INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19-21, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
During a facility inspection conduct March 19-21, 2019, the facility failed to provide documentation of the required 25 training hours for employee # 3.Employee # 3 was hired on August 30, 2012 and promoted to current position on October 6, 2017. Review of employee record shows only 22 hours of individual training for the training year July 1, 2017 to June 30, 2018.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.11 Training Requirements for Counselors the following procedure will take place:
The Clinical Director will ensure that each counselor receives 25 hours of training throughout the fiscal year (June to July). The Program Coordinator at the Gate House for Men will create an excel spreadsheet to monitor the completed training hours for all staff. This documentation will assist the Clinical Director in adhering to this regulation. This procedure will begin taking place 4/16/2019.
The Director of Programs will monitor the progress of this procedure. |
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
During a physical plant inspection conducted on March 19-21, 2019, the facility failed to provide documentation of a sleeping hours fire drill conducted at least every six months. The fire drill log beginning January 28, 2018 and ending January 15, 2019 indicated one sleeping fire drill conducted on July 17, 2018. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 Fire Safety, the following will be implemented:
Beginning 4/15/2019 the Clinical Director will ensure that the fire drills are conducted during the hours that the residents are asleep at least once every 90 days. The fire drills will be unannounced and conducted between the hours of 1:00a.m. and 5:00a.m.
The Director of Programs will monitor this procedure to ensure that the Gate House for Men are adhering to this standard.
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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.
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Observations
During a facility inspection conducted on March 19-21, 2019, the facility failed to provide documentation of missed dosed medications in the Medication Administration Records (MAR) binder. Client # 1 was admitted on September 17, 2018 and was still an active client at the time of the inspection. Client prescription and missing MAR documentation are as follows:Clonidine -1 tablet 1 time per day.September 20, 22 and November 25, 2018.Gabapentin - 2 tablets 3 times per day. September 22, 2018 Doxycycline prescribed 1 tablet 2 times per day.September 21, 2018Client # 2 was admitted on November 19, 2018 and was still an active client at the time of the inspection. Client prescription and missing MAR documentation are as follows:Seroquel - 1 tablet 3 times per day.11:30 am Dose- November 28, December 13, 14, 15, 22, 23, January 2,4,15-17, 264:30 pm dose- December 22, 2018, January 26, 2019.9:30 pm dose- January 22-26, 29-31, 2019Buspar- 1 tablet 2 times per day.9:30 pm dose- January 15-18, 22-31, 2019Prazosin- 1 tablet 1 time per day.January 15-18, 22-25, 2019.Client # 3 was admitted on December 10, 2018 and was still an active client at the time of the inspection. Client prescription and missing MAR documentation are as follows:Prozac (Fluoxetine)- 1 at bedtime.December 16, 2018Divalproex- 2 at bedtimeDecember 15, 2018Wellbutrin- 1 tablet 1 time per dayFebruary 23, 2019Client # 5 was admitted on August 13, 2018 and was discharged on October 13, 2018. Client prescription and missing MAR documentation are as follows:Depakote- BedtimeOctober 6, 2018Doxepin- 2 tablets at bedtimeOctober 6, 2018Buspar- 1 tablet 2 times per dayOctober 6, 2018These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address the citation related to 709.32 the following procedures will be implemented.
During the daily medication times, the staff person responsible for observing the clients self administer their medication will ensure that each medication prescribed is taken by the client. In the event that the client misses a dose of prescribed medication, the staff person will indicate the reason for the missed dose on the medication administration records.
This procedure will be monitored closely by the Residential Program Supervisor on a weekly basis, beginning 4/15/2019.
The Clinical Director will monitor the progress and application of this procedure. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
During a facility inspection conducted on March 19-21, 2019, the facility failed to provide documentation of an inspection, at least quarterly, showing an inventory of all medications including PRN's being stored in the facility.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.32 Medication Control the following procedure will be implemented:
The Clinical Director and the Residential Program Supervisor will inspect all medications onsite on a monthly basis, this inspection will include over the counter medications. In addition, the monthly inspection will be documented, along with the documentation of any medications that would need to be discarded. This new procedure will begin on 4/16/2019.
The Director of Programs will monitor the progress of this procedure.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
During a facility inspection conducted on March 19-21, 2019, the facility failed to provide documentation of verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan in client record #'s 1, 2,3, 4, 6, and 7. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.53 Work as Treatment the following will be implemented:
The Director of Programs has updated the client treatment plan template to include work therapy. The Clinical Director will ensure that all clinicians begin using the updated treatment plan to reflect the frequency of work therapy which is utilized to build on life skills at the Gate House. All clinicians will begin documenting work therapy on client treatment plans beginning 4/16/2019.
The Director of Programs will monitor the progress of this procedure.
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