Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. * Part 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. *Part 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 13, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-site inspection, The Gate House - Lititz 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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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the project failed to ensure that employee's #4 receive at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #4 was hired as a recovery specialist on March 14, 2018 and was due to have the communicable disease trainings no later than March 14, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.11 (c)(1) the following procedure will be implemented:
The Residential Program Supervisor will oversee the annual training plans for all support staff employed at GateHouse for Men. The Residential Program Supervisor will ensure that each new support staff hired at GateHouse for Men receive the required trainings (6 hours of HIV/AIDS, and at least 4 more hours of TB/STD) within two years of the date of hire.
Employee number (4) is scheduled to complete a TB/STD training by 4/30/2020.
The Clinical Director will monitor this procedure. |