INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to have one FTE counselor for every eight clients. The facility has an exception approval to operate with one FTE counselor for every ten clients, but the facility has a client/counselor ratio of 11:1. The FTE counselor ' s ratio calculation is as follows: 100/37.5=2.6666(FTE); 27/2.6666= 10.1252, which equals to a client/counselor ratio of 11:1.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of combined counselor hours devoted to clients by the facilities hours of operation 37.5. Then, to obtain the counselor/client ratio, the total number of active clients is divided by the FTE.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.12 (a) (3) (i) the following will be implemented:
Beginning on 4/30/2021 each clinician will work a 40 hour work week and maintain a case load of 10 clients per our exception which allows us to maintain a counselor to client ratio of 10:1. The Gate House for Men maintains a census of 27 clients. We have roster of two full time Counselors and one Clinical Supervisor. The two clinicians will maintain a caseload of 10 each, and the Clinical Supervisor will maintain a caseload of 7.
The Clinical Director will ensure that this procedure is followed and will monitor it monthly. |
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 one of three applicable discharged client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur seven days, thirty days, and ninety days after discharge. Client # 5 was admitted on July 13, 2020 and was discharged on August 13, 2020. A follow-up was due to occur no later than August 20, 2020 however, the first follow-up information documented occurred on September 1, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.53 (a) (11), the following will be implemented:
Beginning on 4/30/2021, the Program Assistant will complete follow up contacts for each client post discharge at the following intervals: 7 days, 30 days and 90 days. Each follow up contact will be documented.
The Clinical Director will monitor this procedure monthly during the chart audit. |